CARE HOMES FOR OLDER PEOPLE
Pensall House Resource Centre Fairview Way Pensby Wirral CH61 6XL Lead Inspector
Inger Moynihan Unannounced Inspection 15th November 2005 13.30p 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 Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 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. Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Pensall House Resource Centre Address Fairview Way Pensby Wirral CH61 6XL 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) 0151 666 4648 Metropolitan Borough of Wirral Mrs Susan Teresa White Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Two (2) beds to accommodate persons under 65 years of age in an overall total of 25 21st April 2005 Date of last inspection Brief Description of the Service: Pensall House is a two storey, purpose built unit owned and operated by the Metropolitan Borough of Wirral. It is easily accessible to the local facilities and amenities of Pensby and Heswall. Bus routes are close by. The unit is located in a residential part of the Wirral. There are good parking facilities at the front of the unit and wheelchair access is available at the front entrance. Bedrooms are located on two floors with a lift being provided to access these rooms. All rooms are single occupancy with ensuite facilities comprising of a toilet and wash basin. There is sufficient communal space for the number of service users accommodated at the unit which includes a large dining room and a number of lounges. A separate smoking room is provided. Pensall House is furnished and decorated to high standard which provides a homely and comfortable environment for the service users. A range of equipment is provided to assist service users with their bathing and mobility. Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over four hours and was the statutory unannounced inspection for 2005 / 2006. During the last three inspections all of the documentation required for the management of this service has been examined and were kept in good order. In the light of this, this inspection concentrated on speaking to the service users and finding out their views on the standard of care they receive when using Pensall House. What the service does well:
Service users are only admitted into the home on the basis of a full assessment which ensures staff can provide the appropriate package of care. Efficient systems were in place to ensure service users good health. All of the service users spoken to during the inspection confirmed their needs were met in every way. They said the staff were fully up-to-date on all of their particular needs and requirements and they felt well cared for. One service user stated the staff are very good, I cant fault Pensall House in anyway. A varied and nutritious diet is provided to ensure service users interest and good health. One service user commented the food is delicious and the cook is wonderful, nothing is ever any trouble to him. Another service user commented I always get plenty to eat and drink and enjoy the mealtimes because it gives me an opportunity to chat to the other service users. A range of social activities are provided to ensure service users interest and mental stimulation. One resident stated I enjoy the quizzes they keep my mind active. Another resident confirmed the activities were available but said she did not wish to join in and was happy the staff respected her decision. Service users were aware of who to contact if they wished to make a complaint. One service user commented I have absolutely no complaints to make about the care I received at Pensall House. The staff at absolutely wonderful, this was further confirmed by their relative. Procedures were in place to ensure server users were protected from abuse. The standard of the decor throughout the unit remains very high and provides a comfortable and pleasant environment. Service users needs are met by the number and skill mix of staff and staff have completed appropriate training to ensure service users receive the correct level of care. Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 6 The leadership guidance and direction offered to staff ensures service users receive a high standard of care and that the unit is run for their best interest. The health, safety and welfare of the service users was well promoted. What has improved since the last inspection? 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. Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 7 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 Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 8 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): 3 Service users are only admitted into the home on the basis of a full assessment which ensures staff can provide the appropriate package of care. EVIDENCE: All of the service users spoken to during the inspection confirmed their needs were met in every way. They said the staff were fully up-to-date on all of their particular needs and requirements and they felt well cared for. One service user stated the staff are very good, I cant fault Pensall House in anyway. A stoma care nurse visiting Pensall House at the time of the inspection spoke highly of the service provided and stated that her patients received the care they needed. She commented the staff were excellent with a kind and courteous manner and confirmed the registered manager had introduced efficient and effective communication systems into the unit to ensure her instructions and guidance were always carried. Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 9 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): 8 and 9 Efficient systems were in place to ensure service users good health. EVIDENCE: Systems were in place for the safekeeping and handling of service users’ medication and only trained staff are allowed to administer medication. A risk assessment had been carried out in relation to service users who take responsibility for their own medication. All of the service users spoken to during inspection confirmed they received their medication as prescribed by their GP. The service users spoken to during inspection discussed their particular healthcare requirements with the inspector and confirmed the staff looked after them properly. They confirmed they had easy access to relevant health care professionals when necessary which gave them a great sense of security. All of the service users spoken to during the inspection confirmed the staff treated them with respect and dignity is all times and particularly when carrying out personal care. One service user commented the staff of very kind and sympathetic especially when helping me to the toilet or having a bath.
Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 10 When service users are unwell or become vulnerable in anyway, they must rely on the staff to care for them properly. It is clear from the service users comments that staff are providing a standard of care which is in line with good practice and meets service users individual needs. Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 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 and 15 A varied and nutritious diet is provided to ensure service users interest and good health. A range of social activities are provided to ensure service users interest and mental stimulation. EVIDENCE: A range of social activities were provided which the service users confirmed they were free to participate in if they wish. A member of staff takes responsibility for arranging daily activities and plans were being made to provide activities for the Christmas period. One resident stated I enjoy the quizzes they keep my mind active. Another resident confirmed the activities were available but stated she did not wish to join in and was happy the staff respected her decision. During discussion, some service users stated there were no social activities provided at the unit. In the light of this the registered person is required to ensure all service users are informed of the programme of activities provided during their stay. All of the service users spoken to during the inspection confirmed they enjoyed the meals provided. One service user commented the food is delicious and the cook is wonderful, nothing is ever a problem to him. Another service user commented I always get plenty to eat and drink and enjoy the mealtimes
Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 12 because it gives me an opportunity to chat to the other service users. The dining room is a pleasant area which ensures service users enjoy their meals in a leisurely and comfortable environment. The service users confirmed their friends and relatives could visit Pensall House at any time. Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 13 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): 16 and 18 Service users were aware of who to contact if they wished to make a complaint. Procedures were in place to ensure server users were protected from abuse. EVIDENCE: The service users spoken to during inspection said they were aware they could make a complaint about any aspect of the service provided. One service user commented I have absolutely no complaints to make about the care I receive at Pensall House. The staff at absolutely wonderful, this was further confirmed by their relative. Another service users said I cant speak highly enough of the staff, they are absolutely fantastic, I have no complaints to make at all. The registered manager confirmed that all senior staff are up-to-date on the protection of vulnerable adults procedure which was displayed on the staff notice board. She also confirmed that all staff have received training in this aspect of care. The registered manager should be commended for making available to service users a range of information on the different agencies the service users can contact in the event of them being concerned about their safety or welfare. Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 14 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 and 26 The standard of the decor throughout the unit remains very high and provides a comfortable and pleasant environment. EVIDENCE: The standard of furnishings throughout the unit remains very high and the grounds are well kept. An efficient cleaning schedule has been set up and a member of the domestic staff stated they had enough equipment and materials to carry out their work. Sufficient laundry facilities were in place along with systems to ensure the prevention of cross infection. It is clear the domestic staff are working very hard to ensure a high standard of cleanliness is maintained at all times. Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 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): 27 and 28 Service users needs are met by the number and skill mix of staff. Staff have completed appropriate training to ensure service users receive the correct level of care. EVIDENCE: Pensall House has a full complement of staff who are evenly deployed across the week to ensure service users’ care needs are met at all times and to ensure their safety and well-being. The manager confirmed there is a rolling programme of training to ensure the staff are up to date with current good practice and ensure service users welfare and safety during their stay at Pensall House. This training is provided by way of National Vocational Qualification training, external training courses and the use of specific health care professionals such as the stoma care nurse, a representative from Age Concern and the Fire Department. This is a positive aspect of the unit and ensures staff are provided with any range of views on service users safety. Pensall House has an equal opportunity statement and procedure which all staff must be aware of. The registered manager confirmed that training in this area had not been provided for some time and agreed to ensure all staff are updated in this aspect of care to ensure service users specific care
Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 16 requirements are met in relation to their religion, sexuality or cultural background. The registered manager’s approach to training and development is a positive aspect of the unit as it ensures service users are being cared for properly and their needs are being met in accordance with current good practice. The staff spoken to during the inspection demonstrated a clear awareness of their role and their responsibilities with regard to the care of vulnerable adults. Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 17 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, 35 and 38 The leadership guidance and direction offered to staff ensures service users receive a high standard of care and that the unit is run for their best interest. The records relating to the Pensall House amenity fund were not available for inspection. The health, safety and welfare of the service users was well promoted. EVIDENCE: Through discussion the registered manager demonstrated she was aware of her responsibilities with regard to the management of the unit, supervision of staff and the care of service users. This is a positive aspect of a unit and ensures service users are cared for in accordance with their particular needs and requirements. The service users spoken to during inspection spoke highly of the registered manager and staff team and commented on their efficient and
Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 18 helpful manner. This information demonstrates the unit is run for service users best interest. The deputy manager informed the inspector an amenity fund had been set up on behalf of the service users who have made donations to the unit. A discussion took place around the record keeping and auditing system in place for this account. In light of this, the registered person is required to formalise the way this account is being managed and ensure a system of auditing and record keeping is maintained and available for inspection. Safe working practices have been developed and staff have been provided with the appropriate training to ensure service users safety and welfare. The registered person is advised to keep up-to-date with all of the information provided on the Health and Safety Executive and Medical Devices Agency Web Sites. Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 19 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 4 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x x x 2 x x 4 Pensall House Resource Centre DS0000035958.V265039.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? no 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 OP28 Regulation 12 and 18 Requirement The registered person is required to ensure all staff are provided with training on issues of diversity. The registered person is required to ensure the arrangements in place for the keeping of a service users amenity fund are formalised and that all records are available for inspection. Timescale for action 31/03/05 2 OP35 17 31/03/05 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 Refer to Standard OP38 Good Practice Recommendations It is recommended that the registered person keeps up to date with the information provided on the Health and Safety Executive and Medical Devices Agency Web Sites.
DS0000035958.V265039.R01.S.doc Version 5.0 Page 21 Pensall House Resource Centre Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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