Inspection on 15/01/06 for Pensby Hall Residential Home

This inspection was carried out on 15th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Pensby Hall Residential Home 16/10/07

Pensby Hall Residential Home 16/04/07

Pensby Hall Residential Home 05/06/06

Pensby Hall Residential Home 27/02/06

Pensby Hall Residential Home 03/02/05

Pensby Hall Residential Home 04/10/04

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 Pensby Hall Residential Home 347 Pensby Road Pensby Wirral Merseyside CH61 9NE Lead Inspector Lynn Sharples Unannounced Inspection 15th January 2006 09:30 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 Pensby Hall Residential Home DS0000059534.V277219.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. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pensby Hall Residential Home Address 347 Pensby Road Pensby Wirral Merseyside CH61 9NE 0151 648 9730 0151 648 6520 pensbyhall@aol.com 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) Snow Peak Ltd T/A Pensby Hall Paul Charles Stuart Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 2005 Brief Description of the Service: Pensby Hall is a large four-storey building, situated on a main road in Pensby in Wirral. The home is in a residential area, close to shops and other community facilities, including a library. Service users live on the ground, first and second floors in 27 single bedrooms, two of which have en suite facilities. The upper floors are served by a new passenger lift. The main lounge, which has a television and stereo system, is on the ground floor, there is a new large conservatory overlooking the garden. The dining room is adjacent to the main lounge. There are a number of baths and showers throughout the home and the home has a mobile electric hoist, which can be moved between bathrooms and a new fixed bath hoist. Pensby Hall has a pleasant, open garden at the back of the house, a small patio to one side and a gravelled and patio area at the front of the building. Car parking is available at the side of the building and on the road. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home did not know about the visit and took three and half hours. The inspector spoke with service users, relatives and staff. The inspector read files, policies and procedures. What the service does well: What has improved since the last inspection? What they could do better: The following items need to be addressed: Improvements are required to the home’s statement of purpose and service user guide. Repairs to the toilet, frame and window need to be done. The hoist should be risk assessed by an appropriate professional. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 6 Where required locks should be fitted to service users bedroom The remaining bedrooms need decorating. Monthly visits by the Registered Person should be recorded and forwarded to CSCI. Notifications of deaths, illness and other events should be forward to the CSCI office. 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. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 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 Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 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): 1,2,3,6 The homes Statement of Purpose and lack of evidence of the Service User Guide is inadequate and does not provide sufficient information for prospective service users to be clear about the services the home provides to meet their needs. EVIDENCE: The care home has a Statement of Purpose outlining the aims, and objectives, philosophy of the home. The registered manager should ensure that all the items in Schedule 1 of the Care homes regulations 2001 are included in the Statement of Purpose. The Service User Guide could not be found on the day of the inspection, this should be located and made available to all the service users and anyone visiting the home. A written contract and statement of terms and conditions with the home are kept in care files. The care files include assessment details prior to admission and care plans on admission to the home. Pensby Hall does not provide intermediate care. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 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): 7,8,9,10,11 The health needs of service users are well met with evidence some multidisciplinary working taking place. The medication at the home is well managed promoting good health. Personal support in the home promotes and protects service users’ privacy, dignity and independence. EVIDENCE: Care plans and risk assessments and daily reports were available on all of the service user files examined. The manager reviews care plans each month though formal reviews (involving relatives and other professionals) are less common. It was evident from those files examined that appropriate health professionals are involved with service users and that their visits are recorded. The inspector observed staff treating service users with respect and knocking on bedroom doors before entering. Medication was administered safely and efficiently. The treatment room has two windows on the ground floor and would benefit from being secured; the lock on the door is not strong. Controlled drugs are kept in an appropriate cabinet and their administration is correctly recorded in a CD register. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 10 Medication Administration Record sheets for four service users were examined and were found to be accurate and up to date. All service users have individual rooms and most choose to receive guests in those rooms. In the event of a service user’s death, arrangements to be followed are set out in individual case files. Pensby Hall Residential Home DS0000059534.V277219.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): 12,13,14,15 Service users have limited opportunity to exercise their choice in relation to leisure and social activities. Visitors are welcomed at the home and people do call in at the home. The meals in the home are good offering both choice and variety and cater for special dietary needs. EVIDENCE: The activities co coordinator has recently left and the records indicate that limited activities have been offered. The inspector asked that activities be started again and recorded in the activity book. Some trips out were organised last year, but the staff on duty said that the Registered Person was proposing to buy a minibus solely for the use of small groups of service users, which would make it easier to arrange outside visits. A suggestion from the last report that a detailed record is kept of individual service user’s likes and dislikes as regards activities would make it easier to plan activities, which service users enjoyed, has not been actioned. Visitors are welcome at any time and the inspector spoke to one relative who was visiting at the time of the inspection. She was happy with the services provided to her relative. Several service users told the inspector that they go on visits outside the home with friends and relatives. Those service users spoken to confirmed that they are free to make choices as to how to live their lives in the home. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 12 The menu for the week is available on dining tables and in lounges. A choice is available for the main meal each day. Alternatives are provided for any meal if a service user so chooses and service users confirmed this. All of the service users who spoke to the inspector said that they enjoyed the food in the home. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 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): 16,18 Staff have a good knowledge and understanding of Adult Protection issues, which protects service users from abuse. EVIDENCE: The complaints procedure is available to all service users and relatives in the ‘welcome pack’. A complaints book is also available but there were no entries for the past twelve months. Service users who spoke to the inspector were aware of how to complain should they need to do so. The staff team are advised of adult protection procedures as part of the induction programme and the inspector spoke to a member of staff who knew how apply this. An adult abuse procedure and the Wirral Adult Abuse protocol are kept in the home. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 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): 19,20,21,22,24,25,26 Recent investment has improved the appearance of the home creating more comfortable environment for those living there and visiting. The overall quality of some of the furnishings and fittings is poor and places service users and visitors at risk of injury or harm. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 15 EVIDENCE: The home is accessible to service users, the new lift enables access to all floors and staff and service users commented about the improvement of the lift. The Registered Person has a programme of redecoration, which has started. The home has one main lounge and two smaller ones as well as a spacious dining room. The service users welcome the addition of the conservatory, on the day of the inspection five service users were choosing to use it. It is decorated well and has new chairs, it was being heated with oil heaters, and these are being replaced with radiators. During the inspection a number of service users were choosing to spend time in their rooms. Some of the lounge chairs were damaged these are to be replaced as part of proposed changes to communal space. The patio/garden area is well maintained and accessible by wheelchair; the inspector was informed that garden furniture is being purchased for the summer. Toilets and bathrooms were generally clean and well maintained but a number of items needed attention: The floor in one (apparently little used) second floor toilet was badly marked and needs to be replaced. This had been identified at the last inspection. The support frame in one ground floor toilet was badly rusted and must be replaced or cleaned. This had also been identified at the last inspection. The home uses hoists to assist with personal care, one hoist examined in the bathroom on the lower floor, does not meet all the service users needs. On discussion with the staff on duty, it is felt that this is not appropriate for their use and a risk assessment and referral to the appropriate professional is needed. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 16 Bedrooms are properly furnished and, in many cases, personalised. The staff on duty said that the rolling programme of redecoration has begun. This should allow for some variation to the universally white bedroom walls. The vanity units in several identified bedrooms must be replaced. This had been identified at the previous inspection and although some had been replaced others appeared to be damaged. Bedrooms do not have locks and whilst this is a National Minimum Standard it is not in itself a requirement. If a service user requires a lock this must be provided, the home should provide evidence that they have asked service users about this. The Registered Person must provide a lock that is readily opened in a single movement from the inside and can be accessed by staff in an emergency. Individual thermostats in some service users rooms have been fitted, it is recommended that these thermostats are fitted in all the rooms were the water temperature is hot. Water must be delivered to service users safely and the Registered Person may feel that it would be appropriate to fit thermostats in all bedrooms in order to achieve this. In the meantime the Registered Manager must ensure that staff continue to give particular care when assisting service users to bathe. The home was generally clean and odour free but there was a slight malodour in one corridor and in a small number of bedrooms. The causes of this were discussed, as were some of the steps being taken to resolve the situation. It is essential that malodours are eliminated. The advice of incontinence nurses should be obtained as to additional action that can be taken. In the circumstances, suitable laminate flooring would, in the view of the inspector be acceptable in one of the rooms, though it may be possible to fit a more suitable carpet. In one instance a full multi-disciplinary review may help. There was also a crack in the window on the corridor on the first floor, this needs replacing. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 17 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): 27,28,29,30 Staff morale is good resulting in an enthusiastic workforce that works positively with service users to improve their quality of life. EVIDENCE: The rota is well presented and provides for one senior care assistant and at least two care assistants to be on duty throughout the day in addition to the manager. The home also employs a full time cook, a relief cook and general assistants. There is a low sick record for the home. Six staff have NVQ2, and eight are studying for NVQ2. Thus all care staff either have or are studying for an NVQ qualification. The home has a satisfactory recruitment procedure; the staff records could not be accessed, as the manger was not on duty. The home has a training programme but this could not be viewed on the day of the inspection, as the manager was not on duty. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 18 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): 31,33,35,38 The home does not review aspects of its performance through a programme of self-review and consultation, which include seeking the views of, service users, staff and relative. EVIDENCE: The registered manager was formerly the deputy manager of the home and is nearing completion of his NVQ 4. The CSCI office has no record of the monthly visits undertaken by the registered provider or any notification of any serious injury to a service user. The inspector examined files were serious injuries had occurred. Policies and procedures are regularly reviewed. The last service user survey was in 2004; another survey would be beneficial to the home. Service users money is handled either by the service users themselves or their relatives. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 19 The home has regular fire drills; the home must record all the staff that have attended these. On the day of the inspection there was a ladder on a fire escape, this was removed immediately. The home must ensure that all fire escapes are free from clutter. The maintenance of electrical systems and electrical equipment is up to date. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 20 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 1 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 2 X 2 2 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4,5 Requirement The Registered Person must ensure that the Statement of Purpose includes all the contents in Schedule 1. The Service User guide must be available to all visitors to the home. The Registered Person must ensure that the treatment room is secure. The Registered Person must ensure that toilet and bathroom facilities are adequate by carrying out the following: The floor in one second floor toilet was badly marked and needs to be replaced. The support frame in one ground floor toilet was badly rusted and must be replaced or cleaned. (This requirement remains unmet, timescale December 2004). The Registered Person must ensure that the hoist on the ground floor is assessed by the appropriate professional. The Registered Person must ensure that adequate private accommodation is provided for DS0000059534.V277219.R01.S.doc Timescale for action 13/02/06 2 2 OP9 OP21 13 23 13/02/06 26/06/06 3 OP22 23 13/02/06 4 OP24 23 27/03/06 Pensby Hall Residential Home Version 5.1 Page 22 5 OP24 23 6 OP25 13 7 OP25 13 8 9 OP33 OP33 26 37 10 OP38 23 each service user by fitting suitable locks to bedroom doors where the service user has been unable to preserve privacy without such a lock. This requirement remains unmet, timescale, December 2004) The Registered Person must ensure that decoration is adequate by replacing damaged vanity units in those bedrooms identified. (This requirement remains unmet, timescale February 2005). The Registered Person must ensure that unnecessary risks to service users are eliminated by ensuring that hot water is delivered to bathrooms and wash hand basins at a safe temperature. The Registered Person must ensure that the cracked window in the corridor on the first floor is replaced. The Registered Person must visit the home monthly and forward their report to the CSCI office. The Registered Person must ensure that they notify the CSCI office of any death, illness or other events. The Registered Person must ensure that all staff attend regular fire drills and that their attendance is recorded. The fire escapes must remain free from hazards at all times. 27/03/06 13/02/06 13/02/06 13/02/06 13/02/06 13/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 23 No. 1 Refer to Standard OP12 Good Practice Recommendations It is recommended that the home restart the activity programme to ensure that service users are given the opportunity for stimulation and that the service users’ interests, likes and dislikes are recorded. It is recommended that service user survey is undertaken and published and forwarded to interested parties including CSCI. 2 OP33 Pensby Hall Residential Home DS0000059534.V277219.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Liverpool Local 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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