Inspection on 21/04/05 for Pensall House Resource Centre

This inspection was carried out on 21st April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Pensall House Resource Centre 17/10/07

Pensall House Resource Centre 25/04/06

Pensall House Resource Centre 15/11/05

Pensall House Resource Centre 08/12/04

Pensall House Resource Centre 26/08/04

Pensall House Resource Centre 09/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Pensall House Resource Centre Fairview Way Pensby Wirral CH61 6XL Lead Inspector Inger Moynihan Unannounced 21 April 2005 9:30 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 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 F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pensall House Address Fairview Way Pensby Wirral CH61 6XL 0151 666 3632 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Metropolitan Borough of Wirral Mrs Teresa White CRH 25 Category(ies) of OP registration, with number 25 of places Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Two (2) beds to accommodate persons under 65 years in an overall total of 25 Date of last inspection 8th December 2004 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 F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 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 this service. A tour of the premises took place and service users’ records were inspected. A range of staff and nine service users were spoken to during the inspection. What the service does well: What has improved since the last inspection? What they could do better: One part of the medication administration procedure required improvement as it was not entirely possible to check the accuracy of the medication being held in the unit. Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 Page 6 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 F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 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 standard(s) 3 and 6. 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: An assessment of service users individual care needs is carried out prior to any person being admitted into the unit. This assessment is carried out by the registered manager and a member of the rehabilitation team which comprises of an occupational therapist and physiotherapist. Rehabilitation facilities are provided a Pensall House along with a team of specialist health care professionals to support service users in this aspect of their care package. All of the service users spoken to during the inspection confirmed their needs were met in every way. Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 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 standard(s) 7,8,9 and 10. Service users health care needs were met through the care planning process. Shortfalls were identified in some of the medication administration procedures which could result in service users being left vulnerable to the risk of harm. EVIDENCE: Individual care plans had been documented for each of the service users; all of this information had been reviewed and updated. Improvements had been made to the way in which the care plans had been documented. Service users have access to a range of health care professionals and a record is maintained of their general welfare. Systems are in place to ensure good communication amongst staff team with regard to service users’ welfare. All of this contributes to the service users’ safety and well-being. Systems are in place for the safekeeping and handling of service users’ medication and only trained senior staff are allowed to administer medication. A record of the medication entering the building is been made although this was difficult to audit. To ensure the tight monitoring of any medication entering the building, improvements need to be made to the administration systems in place. Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 Page 10 A risk assessment had been carried out in relation to service users who take responsibility for their own medication. While a review and monitoring system had been set up, this had not been formalised, therefore service users may be vulnerable to the risk of not taking their medication correctly. In order to ensure service users’ safety, a formal system of review and monitoring must be established. The service users spoken to during inspection all commented on the high standard of care they received. They confirmed they had access to various health care professionals when necessary and stated the care staff always respected their privacy and indignity. Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 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 standard(s) 12, 13 and 15. The daily routines within the unit are flexible and service users can exercise choice and control over their lives. A varied and nutritious diet is provided with service users medical needs being catered for. A range of social activities are provided which service users may participate in if they wish. This provides a forum for service users to mix as a group and maintain mental stimulation. EVIDENCE: A range of social activities are provided which the service users confirmed they were free to participate in if they wish. A number of the service users confirmed the activities were appropriate and enjoyable. During discussion they confirmed their friends and relatives could visit at any time and they were free to go about their routines as they wished. The menus demonstrated a varied and balanced diet is provided with service users’ medical needs being catered for. All of the service users commented on how much they enjoyed the food and confirmed a choice was always available. Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 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 standard(s) 16 and 18. An efficient complaint and adult protection procedure is in place to ensure service users safety and welfare. EVIDENCE: The unit has a detailed complaints procedure which staff can access when necessary. The CSCI has not received any complaints about this service. Half of the staff have undertaken formal training in relation to the protection of vulnerable adults from abuse. Action is being taken to ensure the remaining staff receive this training in the near future although informal training has been provided in the interim. The service users spoke highly of staff team said they had no complaints to make about the standard of care they received. They all commented on the caring nature of the staff team and said ‘the staff go out of their way to attend to my needs’ and ‘nothing is ever any trouble to the staff’. 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 F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 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 standard(s) 19 and 26. The standard of the decor remains very high and provides a comfortable and pleasant environment for service users. EVIDENCE: The standard of furnishings throughout the unit is very high and the grounds are well kept. An efficient cleaning schedule had 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 are 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 standards of cleanliness are maintained throughout the unit. All of the service users spoken to commented on the high standards of cleanliness throughout the building. Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30. There are sufficient trained and competent staff to meet the service users needs. Thorough recruitment and selection procedures are in place to ensure service users safety and welfare. EVIDENCE: The staff rota indicated the staff were evenly deployed across the week to ensure service users’ care needs were met at all times and to ensure their safety and well-being. The staff spoken to during the inspection confirmed that a range of relevant training was available and that the registered manager encouraged them to become involved in this training. Through discussion it was evident that staff had completed training relevant to the care of elderly service users. The staff spoken to confirmed procedures were in place to ensure their continual development within their role 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. Thorough recruitment and selection procedures are in place which included the necessary security checks to ensure suitably qualified and competent staff are employed in the unit. Only senior staff are involved in the recruitment of staff, all of these staff have completed the necessary training in this area. Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38. The leadership guidance and direction offered to staff ensures service users receive a high standard of care. Efficient and effective systems are in place to ensure the unit is run for the best interests of the service users. The health, safety and welfare of the service users is 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. The staff spoken to during inspection spoke highly of the registered manager and senior staff and said they were supportive and approachable. They confirmed the registered manager encourages them to put forward their ideas and views on the way in which service users should be cared for. Efficient communication systems within the staff team have been established for the smooth running of the unit; staff confirmed the systems are effective for the purpose of their role. A number of the service users spoken to during the inspection commented on how well the Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 Page 16 staff team worked together and praised them for the standard of care they received. The staff spoken to commented that they worked well as a team and enjoyed their work. Discussion with staff confirmed that safe working practices were promoted within the unit and that they were provided with appropriate training for this purpose. All of these issues demonstrate that a high quality of care continues to be provided at Pensall House. Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 4 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 4 COMPLAINTS AND PROTECTION 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 4 x x x x x x 4 Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 Page 18 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 9 Regulation 14 Requirement The registered person is required to ensure a record is kept of the checks that are made in relation to any service user who takes responsibility for the administering of their own medication. (Previous timescale of 8/1/05 not met) The registered person is required to ensure a date recorded on the risk assessment that is completed for all service users who take responsibility for administering their own medication. (Previous timescale of 8/1/05 not met) The registered person is required to implement a system whereby the medication entering the building can be easily audited. Timescale for action 21 May 2005 2. 9 15 21 May 2005 3. 9 17 21 May2005 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. Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 Page 19 Refer to Standard Good Practice Recommendations Pensall House Resource Centre F52_F02_S35958_Pensall House_V222150_210405_Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Liverpool Area Office 3rd Floor 10 Duke Street Liverpool, L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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