Inspection on 27/02/06 for Pensby Hall Residential Home

This inspection was carried out on 27th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 15/01/06

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 27th February 2006 10:30 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.V281752.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.V281752.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.V281752.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th January 2006 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.V281752.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 four hours. The inspector spoke with service users, a director and care staff. The inspector read care files and other documents relating to the home and toured the premises. What the service does well: What has improved since the last inspection? What they could do better: The home should ensure that the service users have a falls risk assessment and that this is included on the care plan and that a record is kept of the stock of paracetamols. Tools should not be left out, posing a risk to service users. The toilet and bathroom facilities should be adequate by carrying out the following: Pensby Hall Residential Home DS0000059534.V281752.R01.S.doc Version 5.1 Page 6 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. By replacing damaged vanity units in those bedrooms unnecessary risks to service users are eliminated. The home must ensure that hot water is delivered to bathrooms and wash hand basins at a safe temperature. The staff should have two references and CRB enhanced checks on file and the staff should receive regular, formal supervisions. A record must be kept of staff attendance at fire drills and the emergency lighting should be tested regularly. 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.V281752.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.V281752.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): 1,2,3,5,6 The homes Statement of Purpose and Service User Guide are good providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to the home. EVIDENCE: The home has recently updated their Statement of Purpose and Service User Guide, these are well written documents and if necessary would be produced in other languages. 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. Service users and their relatives can visit Pensby Hall prior to admission. The home does not provide intermediate care. Pensby Hall Residential Home DS0000059534.V281752.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 Care plans and risk assessments do not reflect the services needs and do not provide staff with the correct information to meet the service users needs. 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. A record of the stock of paracetamols must be kept. 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. There was evidence contained in risk assessments about falls, but no detail on the care plan, one service users file did not contain a falls risk assessment. Some service users plans indicated that they were prone to fall but there was no risk assessment. The care plans and risk assessments should be reviewed in light of this. Pensby Hall Residential Home DS0000059534.V281752.R01.S.doc Version 5.1 Page 10 It was evident from those files examined that appropriate health professionals are involved with service users and that their visits are recorded. Medication was administered safely and efficiently. The treatment room has been secured the windows and the door are plastered over. Controlled drugs are kept in an appropriate cabinet and their administration is correctly recorded in a CD register. Medication Administration Record sheets for three service users were examined and were found to be accurate and up to date. There was no record of the stock of paracetamols kept in the locked cabinet, this will be addressed immediately. All service users have individual rooms and most choose to receive guests in those rooms. The inspector observed staff treating service users with respect and knocking on bedroom doors before entering. 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.V281752.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): 12,13,15 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. Some issues need to be addressed to ensure that the service users have a relaxed mealtime and that they are safe. EVIDENCE: The activities co coordinator has not been replaced and the records indicate that limited activities have been offered. The inspector asked that activities be started again and recorded in the activity book. A suggestion from a 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 still not been actioned. The home has employed someone as the activities coordinator but they have not started work yet. Visitors are welcome at any time and the inspector observed relatives visiting the home on the day of the inspection. Several service users told the inspector that they go on visits outside the home with friends and relatives. 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. The inspector ate Pensby Hall Residential Home DS0000059534.V281752.R01.S.doc Version 5.1 Page 12 their lunch with the service users, the meal was served in a relaxed unhurried manner. The music was rather loud and a quick tempo, the inspector spoke with the staff on duty who agreed to change this. Three service users are separately as there was no room, this is being amended soon. The inspector recommended that a risk assessment is carried out with these three service users to ascertain if they can be left unsupervised. The inspector spoke with several service users about the food and the response was mixed, from good, to the meat being hard to chew, the inspector spoke with the staff on duty and suggested that the service user survey or residents meetings should include comments about the food. Pensby Hall Residential Home DS0000059534.V281752.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. CSCI have receive one complaint and are currently investigating this. 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.V281752.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): 19,20,21,22,24,26 The 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. 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 three service users were choosing to use it. It is decorated well and has new chairs, there were some tools and piping on the floor, which was a potential risk to service users, the staff removed these immediately. 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. Pensby Hall Residential Home DS0000059534.V281752.R01.S.doc Version 5.1 Page 15 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. One bathroom floor had inadequate tape covering a gap in the tiles, this should be removed and an alternative sought. The inspector was informed that all the bathroom floors are being replace soon. 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. The manager spoke with the inspector about the issue of locks on bedroom doors, they explained that they have asked service users and they do not want locks on their doors, the inspector said that this should be recorded in individuals files. The home uses hoists to assist with personal care, one hoist examined in the bathroom on the lower floor, has been examined and a part is being replaced. 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. On the day of the inspection the home was free from malodour and was generally clean. Pensby Hall Residential Home DS0000059534.V281752.R01.S.doc Version 5.1 Page 16 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 whole quality of life. The recruitment procedures and staff training need improving. 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. Of the fourteen care staff employed, 7 have NVQ level 2, 1 has NVQ level 3 and six staff are working towards their NVQ level 2 award. The staff records of five staff were examined, there were some errors found, some staff did not have two references on file and CRBs were not found on some files. The director said that this is already being addressed. The staff records included details of the induction programme, there was no evidence to suggest that the staff have an individual training and development assessment profile and that they have three days paid training per year. Pensby Hall Residential Home DS0000059534.V281752.R01.S.doc Version 5.1 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): 31,33,35,36,38. The home reviews some aspects of its performance through a programme of self-review. The home should consult, with service users, staff and relatives. The lack of supervision leaves the staff without proper direction. EVIDENCE: The registered manager was formerly the deputy manager of the home and is nearing completion of his NVQ 4. The manager is currently on annual leave. The CSCI office has a record of the monthly visits undertaken by the registered provider. A new accident book is being used as the last one was out of date. The last service user survey was in 2004; another survey would be beneficial to the home. The inspector also discussed holding residents/ relatives meetings, regularly. Service users money is handled either by the service users themselves or their relatives. Pensby Hall Residential Home DS0000059534.V281752.R01.S.doc Version 5.1 Page 18 The director explained that staff had not been supervised on a regular basis and this is being addressed. There were no records of staff supervision. The home has regular fire drills; the home must record all the staff that have attended these. The maintenance of most electrical systems and electrical equipment is up to date. The last record of the emergency lighting test was last October. Pensby Hall Residential Home DS0000059534.V281752.R01.S.doc Version 5.1 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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 3 X 2 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 1 X 2 Pensby Hall Residential Home DS0000059534.V281752.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 13,17 Requirement The registered person must ensure that the service users have a falls risk assessment and that this is included on the care plan. The registered person must ensure that a record is kept of the stock of paracetamols. The registered person must ensure that tools are not left out, posing a risk to service users. 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 decoration is adequate by replacing damaged vanity units in those bedrooms identified. (This requirement DS0000059534.V281752.R01.S.doc Timescale for action 27/03/06 2 3 4 OP9 OP19 OP21 13 13 23 06/03/06 28/03/06 26/06/06 5 OP24 23 24/04/06 Pensby Hall Residential Home Version 5.1 Page 21 6 OP25 13 7 OP29 17 8 9 10 OP36 OP38 OP38 18 23 23 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. (This requirement remains unmet timescale January 2006) The registered person must ensure that all staff have two references and CRB enhanced checks on file. The registered person must ensure that the staff receive regular, formal supervision. The registered person must ensure that a record is kept of staff attendance at fire drills. The registered person must ensure that the emergency lighting is tested regularly. 27/03/06 27/03/06 27/03/06 27/03/06 27/03/06 Pensby Hall Residential Home DS0000059534.V281752.R01.S.doc Version 5.1 Page 22 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 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 music played at meal times is not too loud. Also, a risk assessment is completed for the service users who eat unsupervised. It is recommended that the staff receive a minimum of 3 days paid training per year. It is recommended that service user survey is undertaken and published and forwarded to interested parties including CSCI. 2 3 4 OP15 OP30 OP33 Pensby Hall Residential Home DS0000059534.V281752.R01.S.doc Version 5.1 Page 23 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 © 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 Pensby Hall Residential Home DS0000059534.V281752.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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