CARE HOMES FOR OLDER PEOPLE
Pendleton Court Care Centre 22 Chaplin Close Salford Manchester M6 8FW Lead Inspector
Elizabeth Holt Unannounced Inspection 8th February 2006 9:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Pendleton Court Care Centre Address 22 Chaplin Close Salford Manchester M6 8FW Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161 743 9798 0161 737 8080 Southern Cross Home Properties Limited Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (57), Physical disability (1) of places Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. The number of persons requiring nursing care at any one time shall not exceed 25 older persons, aged 65 years and over. That the number of persons requiring accommodation for personal care only at any one time shall not exceed 38 older persons aged 60 years and over within the overall maximum occupancy of 58. The service users requiring personal care only may be accommodated on the first and second floors and rooms 7, 8, 9, 14 and 15 on the ground floor. The service users requiring nursing care may be accommodated on the ground floor only. 1 named individual requiring nursing care as a result of physical disability is accommodated in a designated room on the ground floor. The registration will revert to older people (OP) once the service user leaves the home. That the home complies with the Staffing Notice issued on 28th May 2003 in relation to those service users that are in receipt of nursing care That dependency levels of service users are assessed on a continuous basis and staffing levels are adjusted where appropriate to ensure continued compliance with the Residential Forum Guidance for Staffing in Care Homes for Older People on the unit providing accommodation for service users receiving personal care only. That in addition to care staffing hours a minimum of 20 hours per week will be provided exclusively for activities. The home must at all times employ a manager who is registered with the Commission for Social Care Inspection. 28th June 2005 6. 7. 8. 9. Date of last inspection Brief Description of the Service: Pendleton Court Care Centre is a care home registered to provide accommodation for up to 37 older people requiring nursing care and 21 places for older people requiring personal care only. The home is owned by Highfield Home Properties Limited. The home is a converted mansion house situated in an elevated position at the rear of a residential estate. The home provides accommodation on two floors in single en-suite bedrooms. A passenger lift provides access to each floor. The home is within walking distance of a local park and shops. The home is
Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 5 close to the local bus routes into Manchester city centre and Salford/Eccles and is close to the motorway network. The home’s former manager has returned to manage the home, supported by a care manager. Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection , which took place on the 8th February 2006. During the inspection time was spent talking to the manager, several of the residents, their relatives and some members of staff. In addition residents files, records and other relevant documentation were examined. Since the last inspection the CSCI has received one complaint about this service which was not upheld and one which continues to be investigated. One complaint has been investigated by the home regarding care and general issues which was upheld in part and a training need was identified for staff. As this inspection only looked at a limited number of standards the report should be read together with the previous and any future reports to gain a full picture of how the home is meeting the needs of the people living there. What the service does well: What has improved since the last inspection?
Since the last inspection the home have recruited house keeping staff to make up the staff team. The care planning had improved since the last inspection however some further improvements are required. New documentation has been developed
Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 7 however this system has not yet been fully implemented. There was evidence that residents/relatives were involved in the care planning process. Following a letter of serious concern and a requirement made at the last inspection the home had introduced new menus which included greater choice for the residents. Residents spoken to were complimentary about the food provided. Requirements made at the last pharmacy inspection had been addressed and a requirement involving accurate recordings on the medication administration record charts were checked and were accurate at the time of this inspection. During the last inspection a requirement was made to ensure that all staff files contain the information required in the Care Homes Regulations including two written references and appropriate Criminal records Bureau disclosures. Evidence was seen that this requirement had been met. There has been an increase in the activities provided for residents in the home and relatives were being encouraged to assist staff in finding out the activities and interests that residents wish to participate in. A relatives/residents meeting held in January 2006 was well attended where a number of issues were raised. Accidents were recorded in appropriate detail. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 These standards were not assessed at this inspection. EVIDENCE: The home did not provide an intermediate care service. The other core standards were assessed during the previous inspection. Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 The care planning documentation and risk assessments require improving to ensure all the residents’ health, personal and social care needs are fully met. EVIDENCE: Since the last inspection there was some evidence of improvement, however the care plans did not always contain the detail required. One example included a diabetic resident whose care plan did not contain appropriate information in relation to blood glucose monitoring and recording. Risk assessments were available however these were not clearly integrated into the care plan for the individual residents. New care planning documentation was due to be used following the recent change of the company from Highfield Care to Southern Cross Healthcare. Evaluations were carried out on a monthly basis however these were not always well detailed. A General Practitioner visiting the home spoke positively about the way he was dealt with by the staff and how they carried out his instructions appropriately.
Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, and 14. A range of social activities is provided by the home that matched the residents’ social, cultural, religious, recreational interests and needs. Residents had assistance to exercise choice over their lives. EVIDENCE: At the time of the inspection the activities coordinator provided 10 hours per week, however there has been an increase in the trips out provided and in house entertainers. Plans to include music therapy were being made. A number of residents spoken to were positive regarding activities in the home and there was evidence of good rapport between staff and residents. There was little evidence seen of staff having the time to sit and talk to the residents and two relatives were seen to assist their relative to the toilet due to the demands on the staff at lunchtime. It is recommended the manager reviews the staffing levels and /or the deployment of staff to ensure the needs of the residents accommodated are met at all times. The manager had discussed with relatives at a recent meeting how they could assist in providing life histories for their relatives to be included in the care plan. Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The policies and procedures in place offered protection from abuse for residents. EVIDENCE: A policy was in place for the protection of vulnerable adults and staff were aware of how to put the policy into practice. The manager had received training in the Protection of Vulnerable Adults and had cascaded this to other staff following a requirement made at the last inspection. Staff spoken to were aware of how to act in the event of an allegation of abuse. Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 25 and 26 Residents live in a generally safe environment which suits their individual needs. EVIDENCE: The home was generally clean and free from any malodour at the time of the inspection. Bedrooms were seen to be personalised and there was some evidence of redecoration. The requirement at the last inspection for the removal of the rubbish and kitchen waste at the rear of the property had been addressed. A tour of the premises highlighted that the fridges in the kitchenettes required cleaning. Some residents and staff commented that the home felt “too warm”. This should be monitored and the temperature reduced as necessary. Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 14 During the inspection the call bell went off almost continuously, a discussion with the manager highlighted that an audit should be carried out to ensure staff are responding to this in a timely manner. Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Staff were encouraged to undertake training to equip them with the necessary skills to meet the needs of the residents accommodated. EVIDENCE: At the time of the inspection the home provided care and accommodation for 16 residents requiring nursing care and 38 residents in receipt of personal care only. Residents spoken to said “The staff are very good here. The staff are very kind and caring”. Staff confirmed they had regular training sessions and attended study days on care related topics. Fifteen care staff were attending Eccles College to take NVQ level 2. Staff had recently had medication training. Staff spoken to were positive that the manager encouraged them to study and they felt supported by her. The manager had attended a 5 day course on “Caring for patients with Dementia”. The annual appraisals for the Registered Nurses had not been carried out however the manager planned this in the next two months along with the supervision of the care staff. A structured induction process was available for new staff. Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 35 The home had systems in place to protect the financial interests of residents accommodated. EVIDENCE: The manager has been in post for 7 months and she is fully aware of her responsibilities. The manager has not yet provided a completed application to be registered with the Commission for Social care Inspection. A requirement was made for this to be completed. Policies and procedures were in place to protect the personal allowances of the residents accommodated. Residents, relatives and visitors to the home generally made positive comments about the staff in the home. Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 17 Approximately 15 relatives attended the recent meeting held in January 2006. The manager carried out residents/relatives reviews on a 6 monthly basis. Fire alarm system checks were carried out weekly and staff training in fire safety was being carried out on the afternoon of the inspection. Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X 3 X X 2 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X X Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Service user plans must demonstrate that the home is able to meet the residents needs. They must reflect all the residents assessed needs and provide current, relevant information regarding the interventions required in order to meet those needs effectively. Risk assessments must contain appropriate detail and be into the plan of care. The home is required to supply the Commission For Social care Inspection with an action plan to demonstrate how they intend to meet all the requirements and recommendations made during the Environmental Health Services visit in May 2005. Cleaning schedules for the kitchenettes must be implemented. An application must be submitted to the Commission for registration of the manager. Timescale for action 30/06/06 2. OP7 15 30/05/06 3. OP38 23 22/05/06 4 5 OP26 OP31 16 9 22/05/06 22/05/06 Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 Refer to Standard OP23 OP22 OP27 Good Practice Recommendations It is strongly recommended that the temperatures of the rooms are monitored to ensure they are at an ambient temperature. It is strongly recommended that an audit of the staffs response times to the call system is made. It is strongly recommended that the staffing levels are reviewed to ensure the needs of the residents are met. Pendleton Court Care Centre DS0000006726.V275623.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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