Inspection on 12/07/06 for Pirton Hall

This inspection was carried out on 12th July 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

Pirton Hall 15/06/07

Pirton Hall 15/02/06

Pirton Hall 01/11/05

Pirton Hall 24/02/05

Pirton Hall 07/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Pirton Hall Pirton Road Shillington Hitchin Hertfordshire SG5 3HB Lead Inspector Bijayraj Ramkhelawon Key Unannounced Inspection 12th July 2006 10:00 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 Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 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. Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pirton Hall Address Pirton Road Shillington Hitchin Hertfordshire SG5 3HB 01462 711626 01462 712019 tolladam@bupa.com www.bupa.com BUPA Care Homes (BNH) Limited 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) Mary Tolladay Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Terminally ill (4), Terminally ill over 65 of places years of age (33) Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Any service user admitted to the home with a known diagnosis of terminal illness is accommodated in a single bedroom only. This home may not accommodate Service Users with a Terminal Illnes under the age of 50. 15th February 2006 Date of last inspection Brief Description of the Service: Pirton Hall is a care home providing nursing care and accommodation for up to 33 persons for reason of old age and/or terminal illness. It is owed by BUPA Nursing Homes Limited. The home is a period building on a former country estate. There are extensive attractive grounds with good views of the surrounding countryside. The nearest village shops are about a mile away in Shillington. The market town of Hitchin is a couple of miles away. The home does not have its own transport. Service users accommodation is on three floors connected by a passenger lift. The ground floor consists of a central lobby, the manager’s office, library, lounge, conservatory, dining room, kitchen and servery, laundry, 5 single bedrooms, 2 double bedrooms and a traditional bath and shower room. The first floor consists of 6 single and 6 double bedrooms, a nurse station, a medicine room and a bathroom. The second floor consists of 6 single bedrooms, the hairdressing salon and one bathroom. The ‘Statement of Purpose’, ‘Service User’s Guide’ and the ‘Complaints procedure’ are available for current and prospective service users. Current scale of fees charged is £550 - £950. Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a positive inspection. The atmosphere in the home was very relaxed and service users feedback was very positive. Service users said that they were being ‘well looked after’ and ‘well cared for’. Overall, care plans were well documented with daily progress report of how individual’s needs were being met. There were a dedicated staff team who were aware of service users’ individual needs and good interaction between staff and service users were observed. Staff confirmed that they had attended all the mandatory training. A service user satisfaction survey was carried out and a report has been produced which was displayed on the notice board. The findings of this survey were very positive and service users expressed satisfaction with the service provision. What the service does well: What has improved since the last inspection? Care plans showed that service users’ requests and preferences were respected particularly in relation to personal care and choices. Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 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 Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. Adequate information about the home was available to prospective and current service users. Each service user has an assessment of needs carried out prior to admission. EVIDENCE: Care plans examined included an assessment of needs for each service user. Each service user had their plan of care and daily living based on the assessment of needs. Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 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 and 10 The quality outcome in this area is adequate. This judgement has been made using all available evidence including a visit to this service. Care plans examined showed that service users’ health, personal and social needs were being met. However, care plans must be reviewed, agreed and signed by the service users or their representatives so that they are aware of their identified needs and how these needs were being met. A copy of all prescriptions (FP10) should be kept for ease of auditing and reconciliation of prescribed medicines. EVIDENCE: Service users spoken to confirmed that they were well cared for and their individual needs were being met. Care plans had all the information including assessment of needs, health and personal care being provided, risk assessments and how the needs of the service users were being met. Good, systematic and easy to follow documentation in relation to the treatment of pressure ulcers and catheter care was noted with regular evaluation and monitoring carried out. However, changes in service users’ needs were not reflected on their care plans in particular when a service user with visual Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 Page 10 impairment had a fall, the care plan did not reflect response to falls. There was no evidence to indicate that a review had been carried out. There were no records of whether the dimmer light was left on or other measures would help. However, the care plan did refer to staff reminding the service user to call them. It was noted that some of the care plans were not signed by the service users or their relatives. All service users were appropriately dressed, well groomed and they confirmed that staff addressed them by their preferred names. The home has a “knock and wait” policy on entering service users’ bedrooms, toilets and bathrooms. Staff members on duty were observed to deliver care and to attend to service users’ needs in a manner that was conducive to respect for their privacy, dignity, choice and wishes whilst actively promoting independence where possible. All personal and intimate care practices were carried out behind closed doors. A policy and procedures for care of the dying was in place. spoken said that they were aware of this policy. Staff members The management and administration of medicines were kept in good order except that there were no copies of the FP10 prescriptions kept. The GP’s surgery is attached to the dispensing chemist. Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 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): 12-15 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. Autonomy and choices were exercised. A programme of planned day care activities was devised and displayed. Service users confirmed that there were a variety of activities provided for them. A service user satisfaction survey’s was carried out in autumn last year and the response was very positive. Wholesome, well-balanced and appealing food was served at appropriate intervals and in comfortable surroundings. EVIDENCE: On the day of the inspection, the activity co-ordinator was off duty. However there was a planned activity programme and service users spoken to confirmed that a variety of activities were provided for them during the day. The lunch was observed and tables were laid nicely and a choice of drinks including wine was served and there was individual cutlery. Service users spoken to were complementary of the food provided. Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 Page 12 Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. The home has a robust complaints procedure of which service users and visitors spoken to were aware. Training in the protection of vulnerable adults was provided to all staff. EVIDENCE: A copy of the complaints procedure was available to prospective and current service users. Those spoken to said that they were aware of the complaints procedure but would prefer to speak to a member of staff or the manager if they had any concerns. Staff confirmed that they have received training on Protection of Vulnerable Adults. No complaints have been received since the last inspection. Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 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): 19,22 and 26 The quality outcome in this area is adequate. This judgement has been made using all available evidence including a visit to this service. Pirton Hall is a beautiful period house, set in the heart of the countryside. The house is attractively decorated in its period style and is exceptionally clean offering service users a pleasant environment to live. Some areas of carpet which were badly worn and threadbare must be replaced so that service users and staff are not put at risk of tripping or falling. Call bells must be in working order so that service users are able to call for assistance when required. EVIDENCE: The home and its surroundings offered a pleasant and comfortable environment to its service users. These were kept clean and generally well maintained. Bedrooms were personalised offering a homely, lived in feel. Service users spoken to said that they were happy with their bedrooms and other facilities. Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 Page 15 The home has adequate number of domestic staff and records showed that staff have been provided with training in hygiene and infection control. However, the green carpet on each of the small staircases was badly worn and threadbare. One area in the hallway has been taped in order to prevent trips. Many areas of the carpet were gathered and were a risk to health and safety. Some of the call bells were not working nor there was a system in place for checking that these were maintained in good working order. Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 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 to 30 The quality outcome in this area is good. This judgement has been made using all available evidence including a visit to this service. The skills and experience of staff were varied. There was an enthusiastic, dedicated and caring staff team. Adequate numbers of staff were rostered on duty, ensuring that service users personal care needs can be met in a manner to suit service users, protecting their dignity. EVIDENCE: There was adequate number of staff rostered on duty per shift during the day and night. Staff files examined had all the relevant documents required by this Standard. Staff spoken to confirmed that they have received appropriate training, this included statutory training. They also said that they receive regular supervision and an annual appraisal and they have been given a copy of the General Social Care Council Code of Conduct. Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 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 and 38 The quality outcome in this area is adequate. This judgement has been made using all available evidence including a visit to this service. There were policies and procedures in place to ensure that service users’ rights were protected. There was an enthusiastic, dedicated and caring staff team who took great pride in the service provision. Staff received regular planned supervision. However, risk assessment for the use of electric bed must be carried out so that service user is not put at risk. Fire risk assessment as recommended by Hertfordshire Fire and Rescue Service should be carried out so that every possible fire risk is assessed and minimised. EVIDENCE: Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 Page 18 Staff confirmed that the registered manager operated an open door policy to staff, service users and to their representatives. Good professional interaction between staff and service users was observed. Staff confirmed that they had undertaken all the mandatory training. All statutory records were available for inspection and maintained in accordance with legislation. Staff spoken to were aware that service users can access their records and information held about them in accordance with the Data Protection Act 1998. There were policies and procedures in place to ensure that the health, safety and welfare of service users. However, it was noted that a risk assessment for the use of the electric bed was not carried out. A fire risk assessment as recommended by Hertfordshire Fire and Rescue Service was also not carried out. All accidents and injuries are recorded in the accident book and RIDDOR forms have been completed where applicable. The CSCI has been kept informed of all accidents. A valid insurance certificate was displayed in the reception area and this offered cover of no less than £5 million. Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 x x 1 x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 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. 2. Standard OP7 OP7 Regulation 15 (1) 15 (2) (b) and (c) 13(4)(a) &(c). 23 (2) (c) Requirement Care plans must be agreed and signed by service users or their representative. Care plans must reflect the changing needs of service users particularly when a service user has had a fall. The green carpet on the stairs and first floor must be replaced (Outstanding since last inspection of 15/02/06) Call bells must be in working order and a system must be in place to ensure that checks are carried out on a regular basis. A risk assessment for the electric bed must be carried out with clear instruction of where the handset should be placed. Timescale for action 07/09/06 07/09/06 3. OP19 15/09/06 4. OP22 31/08/06 5. OP38 13 (4) (b) and (c) 31/08/06 Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 Page 21 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 OP9 OP38 Good Practice Recommendations A copy of each FP10 should be kept in the home for ease auditing and reconciliation. Fire risk assessment as recommended by Hertfordshire Fire and Rescue Service should be carried out. Pirton Hall DS0000019553.V303829.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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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