Inspection on 05/06/06 for Pensby Hall Residential Home

This inspection was carried out on 5th June 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 27/02/06

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 6th July 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.V292259.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.V292259.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 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2006 Brief Description of the Service: Pensby Hall is a large three-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 30 single bedrooms, five 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. The fees for the home are £365.73 per week. Pensby Hall Residential Home DS0000059534.V292259.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 6 hours. The inspector spoke with residents, relatives, the manager and staff on duty. The inspector read care files and other documents relating to the home and toured the home. What the service does well: What has improved since the last inspection? What they could do better: The home should ensure that all staff carrying out assessments are trained to do so. That the residents who have experienced a fall have a new falls risk assessment and that this is included on the care plan. All staff who administer medication should receive accredited medication training. Hot meals should be served hot and residents should have their dietary needs addressed. All complaints should be investigated and recorded. All staff should receive training about adult protection. Fire doors should be kept closed, the window restrictors should be fixed and the light on the stairway is fixed. The toilet support frame should be fit for its use and a risk assessment carried out. Residents’ bedrooms should be cleaned regularly and the carpets cleaned or replaced if soiled. Ensuring that hot water is delivered to bathrooms and wash hand basins at a safe temperature should eliminate unnecessary risks to residents. The home Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 6 should be kept clean. The care staff should be suitably trained to perform their work. 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.V292259.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.V292259.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. Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service User Guide provide residents and prospective residents with details of the services the home provides enabling an informed decision about admission to the home. The lack of training regarding admission to the home leaves residents at risk. EVIDENCE: The home is currently amending their Statement of Purpose and Service User Guide to include the three additional bedrooms. If necessary the home would produce these documents in other languages. The Statement of terms and conditions are kept in individuals care files and were examined, terms and conditions of occupancy, including period of notice and overall care and services were included. Qualified professionals undertake assessment prior to admission and these details are included in the care files. The homes current acting manager and Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 9 deputy visit prospective residents prior to admission. Upon admission the home carries out a needs assessment that includes, history of falls, mental state and cognition, social interests, diet and weight. Neither the acting manager or deputy has any training in mental health and some of these assessments were found to be subjective and not based on evidence. This leaves the residents at risk of the wrong treatment being offered and being stigmatised. Prior to admission residents can visit and usually relatives visit before making a decision to stay. The residents have a four week trial period to ascertain if they wish to stay longer. The home does not provide intermediate care. Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. Risk assessments do not provide the staff with the correct information to meet service users needs. The lack of training for staff who administer medication leaves residents at risk of harm. The health needs of residents are met with evidence of some multidisciplinary work taking place. EVIDENCE: The deputy manager, who also completes the management of risk assessment form, reviews the care plans monthly. Some residents had experienced a fall the correct documentation was completed in terms of the accident book, it was difficult to ascertain if the falls risk assessment had been reviewed. There was evidence in the care files and residents and relatives confirmed that they visit the doctors when necessary. One file did not accurately record when the doctor had visited and it appeared that the doctor had not visited this year, but the resident and acting manager confirmed that they had seen the doctor Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 11 this year. The home has a treatment room where the doctors and nurses that visit the home can access. None of the current residents in the home self medicate. The deputy or named carers in the home administer all medications for residents. The protocols for the receipt, storage, disposal, and documentation of medications in the home are in accordance with the National Minimum Standards (NMS). One the day of the inspection the carer administering the medication did not ensure that residents took their medication. Not all the staff administering medication had received accredited training in medication. Staff were observed treating the residents with respect and knocking on residents bedroom doors before entering. Residents can receive medical examination and treatment in their own rooms or treatment room. Residents and relatives said that the care staff were nice but concerned that most of the staff had left and “there were a lot of new faces”. In each care file there is a resident/relatives wishes in the event of death form which details arrangements to be followed, in this event. Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 12 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 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. Residents have some opportunity to exercise their choice in relation to leisure and social activities. The meals at the home need improving to ensure that residents receive an appealing diet. EVIDENCE: A new activities coordinator started working at the home two weeks ago; on the day of the inspection some residents were making fans. The coordinator had several ideas of activities to start at the home, these included arts and crafts, healthy eating, chair exercises and quizzes. The residents spoken with commented on how keen the coordinator was and some were pleased to be engaged in activities. The records indicate that more activities are being offered at the home, however, these are brief, in detail. Visitors are welcome at any time and relatives were observed visiting their relatives. Some residents go on visits outside the home with relatives. The home does organise two or three outings a year. Residents or their relatives handle their financial affairs. Residents’ bedrooms were observed to be decorated with personal possessions. Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 13 From an informal discussion with residents, the home has extended mealtimes, the menus examined were found to provide a choice for the main meal. At teatime the residents had a choice of a hot meal or sandwiches. Some residents complained that their hot meals were sometimes cold and that the meat was tough. One resident said that due to their medical condition it was not advisable to eat pastry and at least two meals a week contained pastry. The home must ensure that all residents’ dietary needs are addressed. All these concerns were discussed with the acting manager. Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 14 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 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to this service. The home has a documented complaints procedure to ensure residents’ views are listened to and acted upon. Systems are in place to ensure residents are safeguarded from abuse and harm, although not all the staff team have completed training in this area, which could leave service users vulnerable to the risk of harm. EVIDENCE: The home has one record of a complaint that has been investigated and upheld. The CSCI has received four concerns regarding the home. Residents spoken with were aware of how to complain and one relative spoke of a recent complaint, this was not recorded in the complaints book. The complaints procedure is available to all residents and relatives in the “ welcome pack”. An adult procedure and the Wirral “No Secrets” adult protection protocol are kept at the home. Staff demonstrated an awareness of how to ensure service users were protected from abuse, although not all staff have completed training in this area. To ensure staff are fully up-to-date on the different types of abuse that can occur and the subtle nature of abuse, the registered person is required to ensure all staff are provided with training in this area of care. Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 15 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): 19,20,21,24,25,26 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to this service. Some of the fittings at the home are poor placing residents at risk of injury or harm. At present the comfort and well being of the residents is compromised because of lack of basic cleanliness. EVIDENCE: The home has one main lounge and two smaller ones as well as a dining room. The conservatory is well decorated and does have air conditioning, the doors were open to assist with access to the patio and it was warm in the conservatory, it is recommended that a thermometer is placed in the conservatory to ensure that the a comfortable temperature is maintained at all times. A fire door was left open and a window restrictor on the first floor was broken, placing residents at risk of injury or harm. The hall light was broken and it was dark placing residents, staff and visitors at risk of harm. Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 16 Toilets and bathrooms were generally clean and well maintained, the support frames in the toilets were loose and one had a support rail missing this leaves the residents at risk of falling. Bedrooms are properly furnished and in many cases, personalised, the damaged vanity units have been replaced. Some residents and relatives spoken with complained about the cleaning at the home and in particular the bedrooms, one relative said that under their relatives bed was “thick with dust” and the room was malodourous and there seems to be no plan of cleaning. There is one cleaner who has recently left, leaving the care staff to clean the home. One relative said that there were no vases to put flowers in the bedrooms. Individual thermostats in some residents rooms have been fitted, it is recommended that there is a risk assessment in place for 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 residents to bathe. On the day of the visit the home was generally free from malodour but was not clean. Pensby Hall Residential Home DS0000059534.V292259.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 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment practices are good and appropriate checks are carried out, ensuring that residents are protected from harm. The lack of ongoing training for staff leaves the residents at risk of harm. EVIDENCE: The rota indicated that there were sufficient staff on duty. The home must ensure that staff left in charge of the home are least aged 21 and this includes night staff, there was one occasion when the home had completed the rota and did not comply with this, they were informed about this and rectified this error. The lack of domestic staff means that the home is not free from dirt or unpleasant odours. One member of staff works over 50 hours a week on a regular basis, the home must ensure that this workers practice is safe. Of the fourteen staff team five have completed the NVQ level 2, three are completing the award and the remaining six are to commence the training shortly. An examination of a sample of staff records indicated that all staff had two references, enhanced CRB checks, statements of terms and conditions on their personnel file. Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 18 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. The lack of training in areas such as mental health and medication leaves the residents at risk of harm. Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 19 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 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. The home reviews aspects of its performance through a programme of self review. EVIDENCE: The current manager is on long term sick leave and there is an acting manager in place, a deputy and a manager from another home overseeing the management of the home. The CSCI office has a record of the monthly visits undertaken by the responsible person. The home undertook a resident survey in May this year. The residents would benefit from participating in regular residents/relatives meetings. Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 20 Service users money is handled either by the service users themselves or their relatives. Since the last inspection the staff team have received one formal supervision. The home must ensure that care staff receive formal supervision at least six times a year. The maintenance of most electrical systems and electrical equipment is up to date, the last recorded water temperature test was done in January. The last fire drill was in February, the home must ensure that all day staff receive at least two fire drills a year and that night staff receive at least three fire drills a year. Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 21 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 2 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 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 2 X X 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 22 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 OP3 Regulation 12 Requirement The registered person must ensure that all staff carrying out assessments are trained to do so. The registered person must ensure that the residents who have experienced a fall have a new falls risk assessment and that this is included on the care plan. The registered person must ensure that all staff who administer medication receive accredited medication training. The registered person must ensure that hot meals are served hot and that residents receive wholesome and nutritious food. The registered person must ensure that all complaints are investigated and recorded. The registered person must ensure that all staff receive training about adult protection. The registered person must ensure fire doors are kept closed, the window restrictors DS0000059534.V292259.R01.S.doc Timescale for action 04/08/06 2. OP7 14 04/08/06 3. OP9 13 06/03/06 4. OP15 16 13/07/06 5. 6. 7. OP16 OP18 OP19 22 19 13 13/07/06 04/08/06 13/07/06 Pensby Hall Residential Home Version 5.1 Page 23 are fixed and that the light on the stairway is fixed. 8. OP21 23 The registered person must ensure that toilet support frame is fit for its purpose and a risk assessment is carried out. The registered person must ensure that residents bedrooms are cleaned regularly and the carpets cleaned or replaced if soiled. 04/08/06 9. OP24 23 04/08/06 10. OP25 13 The registered person must 04/08/06 ensure that unnecessary risks to residents are eliminated by ensuring that hot water is delivered to bathrooms and wash hand basins at a safe temperature. (This requirement remains unmet timescale 27/03/06) The registered person must ensure that the home is kept clean. The registered person must ensure that the care staff are suitably trained to perform their work. 04/08/06 04/08/06 11 12 OP26 OP30 23 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP19 Good Practice Recommendations It is recommended that staff record in detail the daily records. It is recommended that a thermometer be placed in the conservatory to ensure that the comfortable temperature is maintained at all times. DS0000059534.V292259.R01.S.doc Version 5.1 Page 24 Pensby Hall Residential Home 3 OP27 It is recommended that staff that work over 50 hours a week are regularly monitored to ensure that they are safe to work. Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Pensby Hall Residential Home DS0000059534.V292259.R01.S.doc Version 5.1 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!