Inspection on 30/04/07 for Pocklington House

This inspection was carried out on 30th April 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Pocklington House 31/01/06

Pocklington House 18/07/05

Pocklington House 23/09/04

Pocklington House 24/05/04

Similar services:

Coopers Mill Ltd

Newton Court (1-2)

Newton Court (3-4)

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

CARE HOMES FOR OLDER PEOPLE Pocklington House Eastbury Avenue Northwood Middlesex HA6 3LN Lead Inspector Mrs Jan Sheppard Unannounced Inspection 30th April 2007 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 Pocklington House DS0000019497.V336193.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. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pocklington House Address Eastbury Avenue Northwood Middlesex HA6 3LN 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) 01923 824585 01923 842237 Lavinah@pocklington-trust.org.uk Thomas Pocklington Trust Miss Lavina Hall Care Home 35 Category(ies) of Sensory impairment (35), Sensory Impairment registration, with number over 65 years of age (35) of places Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 Brief Description of the Service: Pocklington House is provided by the Thomas Pocklington Trust (a charitable organisation). It is a purpose built care home providing care and support for thirty-five visually impaired service users mainly in the old age category. The home is situated in the village of Northwood. Northwood Underground station and various bus routes are within walking distance. There are parking bays to the side of the building. Accommodation is offered in three separate wings, one of which is single storey and the other having two floors. All the bedrooms, except for one, are single rooms. On the first floor there is a wide hallway furnished with easy chairs and a display of indoor plants. The kitchen, laundry and staff room are located in the basement. The dining room, administration offices, library, recreation room and the lounges are situated on the ground floor. There are ample community areas for the use of the service users and their visitors. The main lounge provides access to a patio and terrace with awnings in place and comfortable garden furniture. There are also seating areas at the entrance to the building. By the patio is a sensory garden. A summerhouse is situated at the bottom of the garden. The surrounding grounds have safe pathways and handrails to facilitate the service users mobility around the grounds. The current fees are £ 502.61 per week. Copies of the homes complaints procedure and last inspection report are available in the homes entrance hallway. Other information about the service is provided in the Statement of Purpose and Service User Guide. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day; a number of residents were spoken with some in small groups and others individually. Discussions were had with the manager and deputy manager as well as with other staff on duty and with a number of visitors and relatives. A volunteer who visits the home regularly was also consulted as were the cook, handyman and laundry worker. The comments in this report reflect the findings made by the inspector during that visit and also take account of information gathered over the past months from the manager and by way of the surveys completed by residents and their relatives. This was a positive inspection with the entire key standards examined met. There were no outstanding requirements from the last inspection. At the time of this inspection Pocklington House had a calm, peaceful and homely atmosphere, where staff and residents were seen to be interacting very positively together. The staff understand the importance of residents being supported to take control of their own lives and great emphasis is placed on them being continually consulted about how the home is run. The residents reported to the inspector that they were very happy living there and that they had good choices about their interesting and enjoyable life styles. What the service does well: Pocklington House continues to offer an excellent service and a high quality of care for service users with a sight impairment. This care is planned to meet the needs of each individual in a holistic manner. Great emphasis is placed on enabling residents to retain all aspects of their independence for as long as it is safely possible for them to do so. Excellent training opportunities are offered for staff and consequently there is very good staff retention offering continuity of care to the people who use the service. The percentage of staff holding required qualifications is well above the minimum standard required. Comments from the service users with one exception confirmed their total satisfaction with the quality of the services they receive. One said, “This is such a lovely home everyone is so kind and helpful I feel very well cared for and even cherished by the staff I couldn’t ask for better”. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Pocklington House DS0000019497.V336193.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 Pocklington House DS0000019497.V336193.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 - Standard 6 is not applicable, as this home does not offer intermediate care. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. Admissions are not agreed until a full needs assessment has been carried out and the manager is satisfied that Pocklington House is the right environment to be able to meet these needs. Sufficient information is provided for prospective residents and their families to enable them to make an informed choice about admission. EVIDENCE: Prospective service users and their relatives are given the information they need about the home and the services that it offers to enable them to make an informed choice about admission. Written information is provided in a format that can be accessed by the prospective resident according to their degree of sight impairment. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 Page 9 The manager carries out a needs assessment in the prospective residents home or other setting to ensure that their needs could be met at Pocklington and to make an initial assessment as to the possible compatibility of the applicant with the existing residents. Applicants are then invited to visit the home, view their prospective room, meet with other residents and spend the day sharing in with any activities and meals as they wish. Relatives are also given the opportunity to visit and access the facilities and suitability of the home. All new admissions are subject to a trail period. One resident recently admitted to the home told the inspector that they had settled very happily they said, “ I can only speak very positively about the manner in which my admission here was arranged. Now it is such a relief to be here and not to have the continual stain of managing living alone in the community with my deteriorating sight … it is just so much easier and I am very happy that I came here.” At the time of this inspection the home was full and had a waiting list of applicants waiting for assessment. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. People who use this service experience excellent quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. The residents are actively involved in making decisions about their own lives, planning their care plans and the social support that they receive. They are continually consulted about their wishes and about how the service runs. Medication is administered in a safe manner. EVIDENCE: Individual care plans examined were seen to be person focused and to concentrate on the individual’s strengths and personal preferences. They were clearly set out, well maintained and showed evidence of the resident’s agreement with their content and of their involvement with their regular review. All care plans seen contained up to date risk assessments. Several residents commented favourably to the inspector about the key worker system that is in place. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 Page 11 Pocklington House has good support from local GPs, the District Nursing Service and other health care professionals who attend regularly and who (as seen on the day of this inspection) respond very promptly if requested because of some unforeseen circumstance. Residents who spoke with the inspector on the day of this inspection all confirmed that their health and care needs were very well met by the home. Since the last inspection the home has introduced a new Monitored Dosage System (MDS) for medication storage and administration. New equipment and training for staff was provided by the supplying pharmacy. The managers discussed with the inspector how this new system is working and acknowledged its various improvements on the previous system. Storage and administration records examined were found to be clearly and accurately maintained. It was noted photos are not included on the new MAR sheets or that a method of evidencing the manager’s weekly checks of the accuracy of the administration records has not been established. The arrangements for the seven residents who currently administer their own medication were seen to be in order with appropriate safe storage facilities provided in their rooms and current risk assessments in place. The community pharmacist visited to review and audit the medication system on 26/1/07. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People who use this service experience excellent quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. The residents’ diverse social and activity interests and needs are very well supported. A well-balanced nutritious and variable menu of freshly cooked food is provided following the choices made by the residents. EVIDENCE: The residents in their written replies (surveys) to the Commission and during their discussions with the inspector confirmed that their social, educational, cultural and recreational needs and aspirations are all very well met. Each resident has an individually planned activities programme that gives him or her every opportunity to participate in the activities they prefer. Individual members of the homes staff deliver some of these activity programmes and they are assisted by a number of volunteers who visit regularly to both assist with groups and classes and to offer individual reader assistance to particular residents. All volunteers working in the home have been subject to CRB checks. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 Page 13 Two craft instructors visit each week to promote various crafts; knitting being a particularly popular class with many of the very high quality items produced being sold to raise funds for the home. Staff reported that the monthly baking class and the weekly exercise classes are also very popular along with Carpet Bowls, Aromatherapy, Massages and Hand and Foot Pampering. Residents mentioned to the inspector the planned summer outings to Aldenham farm for a cream tea, to a seaside fish restaurant and for a trip on a Canal Boat. Several also spoke of their regular visits to a local community social club. On the day of this inspection one resident was waiting for transport to take them to attend a Bridge Class and several others were seen to be making their way to the hairdressers. Relatives and friends are invited to in-house entertainment and birthday parties. The manager reported that many of the residents are fortunate to receive frequent visits from family and friends, who often live many miles away. To facilitate their journeys a visitors Sunday lunch scheme is in place which an increasing number are taking advantage of, thereby meaning that weekends are often very busy times in the home. A variety of in-house classical concerts and other shows that are subsidised by Pocklington House continued to be provided, as are also accompanied shopping trips and visits to the theatre. The services of a number of experienced chefs are retained who provide freshly cooked dishes for each meal which are of good quality, nutritionally balanced and offer good variety. The residents were very complimentary about their food, confirming that there was always sufficient to eat and that good choices were freely available. Special diets are catered for and birthdays and other celebratory days are specially accommodated. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience excellent quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. Residents understood and were familiar with the complaints procedures and reported they would be able to use these if needed. The policies and procedures concerning Safeguarding Adults (Adult Protection) and Whistle Blowing protect the service users. EVIDENCE: There have been no complaints received since the last inspection regarding the services provided. The complaints policy and procedures are well published and are freely available in the entrance hallway of the home. The residents spoken with appeared to have a good understanding of this and confirmed that if they needed to they would speak to the manager about any thing that they were not happy with. A record of compliments is also maintained, a number having been received since the last inspection. There have been no incidents concerning Safeguarding Adults since the last inspection. Staff consulted were familiar with the procedures concerning this and of what their role would be if they ever had any reasons for concern. The records evidenced that staff training on this subject was maintained up to date. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use this service experience excellent quality outcomes in this area. This judgement has been made using a variety of evidence including a visit to the service. The physical design and layout of Pocklington House enables residents with sensory impairment to live in a safe, well-maintained and comfortable environment that encourages them to retain their independence. EVIDENCE: The service users live in a clean, safe and well-maintained environment. They have access to safe and comfortable indoor and outdoor facilities. The premises have CCTV cameras in situ and security devises on exit doors. The residents all occupy individual bedrooms with en-suite facilities; these were very well appointed, personalised to meet their individual tastes and to reflect particular interests and hobbies. The home is of a very spacious design and has a number of specialist features including raised large lettering, colour Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 Page 16 coding and protrusions on hand rails to indicate the end of a rail, along with special lighting, all these features designed to ensure the residents safety and encourage independence. Pocklington House has an accreditation from the RNIB for the quality and arrangement of these design features giving good accessibility and safety to sight impaired residents. Residents spoken with confirmed that the home and garden very adequately met their accommodation needs and that they felt safe and comfortable in the environment. The home is subject to regular redecoration and refurbishment and the ongoing maintenance programme evidenced that a refurbishment of an assisted bathroom with more modern facilities is planned. The decoration throughout the home is attractive, cheerful and maintained to a high standard. Several residents commented on the very particular cleaning standards that the housekeepers adhere to. One reported, “Everything is kept spotless”. The records evidenced that the building is subject to regular risk assessments and the manager discussed with the inspector the particular measures that have been taken to remedy a problem relating to health and safety. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use this service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. Sufficient numbers of experienced, skilled and well-trained staff are employed to support the residents and maintain the smooth running of the home. The robust recruitment practices give protection to the service users. EVIDENCE: The service users are supported and protected by the robust recruitment and selection policy and procedures. The records examined for recently recruited staff evidenced that the home had followed its stated procedures and that the required checks including verified references, CRB and work permit checks had been made. The replies received from residents and relatives confirmed that there are plentiful staff available at all times to support their care needs, activities and aspirations in an individualised manner. Pocklington House is fortunate in retaining a stable core group of staff many that have worked at the home for many years. Staff who have left since the last inspection have all done so because of personal or domestic reasons, not because of any dissatisfaction with their employment conditions. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 Page 18 A comprehensive training programme continues to be provided which staff confirmed contributes to the good staff retention record. There is an expectation that all care staff obtains NVQ at level 2; five also now hold NVQ at level 3 and one Night team leader has attained NVQ at level 4. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. People who use this service experience excellent outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. The management and administration of the home is based on openness and respect. All the management team are experienced qualified and competent. Effective quality monitoring systems are in place to ensure that people who live at Pocklington House are central to the services provided. EVIDENCE: The manager and deputy manager, who are both qualified managers and registered nurses, have worked together at Pocklington House for many years and this stability has no doubt contributed to the consistently good maintenance of the administration and management of the service. They both promote equal opportunities via their good people management skills and their Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 Page 20 thorough understanding of the importance of person centred planning to ensure effective outcomes for the residents in the home. The smooth running of this service was evidenced by the inspector on the day of this unannounced inspection. The home is well run with staff that is sufficiently competent to ensure the smooth running of the service, whatever unexpected events arise. It is run in the best interests of the service users with the highest priority being given to their health, safety and welfare to promote their protection. Through their regular supervision process the managers ensure that staff follow the policies and procedures of the home. Practice and performance issues are discussed both during individual supervision meetings, at team meetings and during in-house staff training sessions. The records evidenced that staff supervision is pre-planned, conducted at regular intervals and is adequately recorded with learning outcomes noted these to inform the annual appraisal record compiled for every staff member. Record keeping was found to be of a consistently high standard and evidenced that regular health and safety checks are carried out so to promote the safety of the residents. Environmental risk assessments, water temperature checks, accident and incident recording and fire alarm testing records were examined and were well maintained. One resident’s written reply to the inspector commented that although they felt sure that the fire arrangements were adequate she did not think that residents were reminded of these with sufficient frequency. The manager has been informed of this comment. Records are kept securely and staff were aware of the requirements of the Data Protection Act. The managers actively promote health and safety performance through the regular quality assurance programme for which it always receives a very full response from the residents. The surveys sent out by the Commission were also very thoroughly completed with a high number being returned. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 4 4 x x x x x x 4 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 4 x 4 x 4 x x 4 Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? no 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. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations It is recommended that photographs are attached to individual MAR medication administration recording sheets to assist staff when administering medication and that a system to evidence when management checks of the accuracy of these recordings is established. Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Pocklington House DS0000019497.V336193.R01.S.doc Version 5.2 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. 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. 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