Inspection on 11/07/05 for Pretoria Court Complex Care Home

This inspection was carried out on 11th July 2005.

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

Pretoria Court Complex Care Home 03/10/07

Pretoria Court Complex Care Home 31/10/06

Pretoria Court Complex Care Home 19/12/05

Pretoria Court Complex Care Home 03/11/04

Pretoria Court Complex Care Home 21/04/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE PRETORIA COURT COMPLEX CARE HOME Corbridge Road Medomsley Consett Co Durham DH8 6QY Lead Inspector Stephen Ellis Unannounced 11th July 2005 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 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 and Care Homes for Adults 18 – 65*. 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. PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pretoria Court Care Complex Address Corbridge Road, Medomsley, Consett, Co Durham, DH8 6QY Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01207 561880 01207 563094 Alliance Care (Trendlewood) Ltd (wholly owned subsidiary of Four Seasons) Mrs Christine Munro Marr Care Home 91 Category(ies) of Old age (67), terminally ill (3), physical registration, with number disability (24) of places PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3rd November 2004 Brief Description of the Service: Pretoria Court Complex is a large, partly purpose built establishment, located in a rural setting with spectacular views from many rooms overlooking the Derwent Valley. It is provided by the Four Seasons Health Care group. The care home complex provides accommodation for service users with nursing or personal care needs. It is staffed with registered nurses and care staff, who are supported by a team of ancillary staff, including cooks, domestics and handyman. The home is divided into separate units to enable service users with different care requirements to be catered for: Edmundbyers House (37 beds) and Blanchland House (30 beds) (currently vacant) are for older persons (over 65 years); Stanhope Suite (24 beds) is for younger adults with physical disabilities (18-65years). All bedrooms are single rooms and there is a good range of sitting and dining areas for communal use. Most bedrooms are supplied with en suite toilet and wash hand basin. There are pleasant garden and patio areas around the home and ample parking space for visitors. The Registered Manager for the whole complex is Mrs Christine Munro Marr and she is supported in her duties by a Deputy Site Manager, Mrs Anne Johnson, who is responsible for the Stanhope Suite. A Deputy Manager is also in post. PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 4 hours. The inspector looked around the building, examined a number of records and spoke with 16 service users, 4 relatives and 4 members of staff. What the service does well: What has improved since the last inspection? What they could do better: Improved ventilation to several widow-less bathrooms/shower rooms is still required. The second floor call bell system on the Edmondbyers unit needs to PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 6 be upgraded so that the room number shows on the warning panel. The home has a little further to go before it achieves the target of at least 50 of its care staff qualified to NVQ level 2 or above (it expects to reach this percentage during 2005). 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. PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6-10 and 18–21) (Standards 11–17) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37–43) PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. 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. Prospective service users have an opportunity to “test drive” the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 (Older People) and 2 (Adults 18-65) No service user moves into the home without a comprehensive assessment of needs and aspirations having been carried out. EVIDENCE: Service users and relatives commented that service users’ needs, aspirations and expectations were being addressed in accordance with their initial assessments carried out prior to their admission. An examination of care plans confirmed that this was the case, with details documented of individual assessments and reviews. Particularly impressive were the memory diaries being created for service users with the help of service users and families. These helped to express and focus things that were important for the individuals concerned. PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6-10 and 18 –21 (Adults 18-65) 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. Including their physical and emotional health needs. 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. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. Service users receive personal support in the way they prefer and require. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 7, 9, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10, 11 (Older People) and 6, 7, 9, 18, 19 (Adults 18-65) There are good arrangements for health and personal care, with service users’ individuality, preferences and aspirations being taken into account, along with their needs. People are treated with care and respect and their right to privacy, choice, independence and fulfilment is upheld. EVIDENCE: PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 10 Comments received from service users and relatives indicated high levels of satisfaction with the arrangements for health and personal care. For example, one relative whose mother had recently died at the home, said: “My mother was exceptionally well looked after during the 4 years she was resident here. There were never any problems. She was always clean and tidy and she was quite happy here. I can’t praise the staff enough. They were all lovely with her. They work very hard here. This home is always welcoming and there is no unpleasant odour.” Another relative said: “I think it has been very, very good. They keep an eye on all his medical needs. I always find when you come in it has a friendly feel to the place, with management and staff being very approachable, with very good communication. They provide a personal service, treating my father as an individual. They try very hard to provide social activities that are relevant, whilst allowing people the right to choose how they want to spend their time. The home is clean and Dad’s clothes are always washed etc.” A third relative also expressed her appreciation of the service (being received by her son). She was very pleased with the standard of care and personal attention being provided. She was always made welcome when she visited and was confident that her son’s needs were being fully addressed. She said she could talk with the staff and management about any matter and described the communication as very good. Such comments were typical of those received on the day, and were borne out by the care plans that were detailed, comprehensive and informative about the individuality of the service user. They contained risk assessments, which were balanced against promoting independence, responsible risk taking and personal fulfilment. People’s health and social care needs were fully addressed and kept under review. Linked to this process were the memory diaries that were being compiled for each service user. These were excellent, personal and reflecting the unique identity of each service user, helping to promote understanding and good communication with service users and their families. Very good rapport between service users, relatives and staff was evident. This process is helped by the good programme of social and recreational activities provided, and the formal consultation meetings with service users that are held every 2 months. PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 11 – 17 (Adults 18-65) are: 12. 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. Including opportunities for personal development. Service users engage in appropriate leisure activities. Service users maintain contact with family/ friends/ representatives and the local community as they wish. And have appropriate personal, family and sexual relationships. 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. 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15, 16 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 (Older People) and 12, 13, 15, 16 (Adults 18-65) The arrangements for daily life and social activities are very good, encouraging choice, independence and personal fulfilment. There are good links with the local community. EVIDENCE: Service users and relatives commented positively on the varied and stimulating programme of social and recreational activities provided. These included parties celebrating birthdays and special events (e.g. the end of the second world war, wimbledon tennis, mothers’ day, diamond wedding anniversary etc.) plus coffee mornings for various charities, and seasonal fairs (e.g. spring and summer). Various floor and board games are enjoyed, along with music and movement and gentle armchair exercises using a lightweight ball. Individual activities are encouraged, including aromatherapy massage, artwork, computer use, pat-a-dog, manicures and hairdressing. Some service users on the Stanhope Suite enjoy a drink, a takeaway meal and a film on a PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 12 Saturday night in an upstairs lounge. A good number of service users go on outings in the minibus and visit the cinema and theatre locally. There are visiting entertainers, who try to involve all the residents who wish to participate. Families and friends are invited to join in social events and all relatives spoke positively of this aspect of the service. A diamond wedding anniversary was recently celebrated at the home and an article and picture appeared in the local paper to record the event. Of particular note at this home is the creation of memory diaries for all service users, which is an ongoing process. These were most impressive, using text and photographs and other documents to illustrate the life story and interests of the service user concerned. These had been compiled with the help of the individual service user and their relatives. The two, part time activities coordinators (one for each unit) take the lead in organising events and in developing the memory diaries. Service users confirmed that their individuality is acknowledged and respected and that they are encouraged to exercise choice in their daily lives. Formal meetings with residents are held every two months, but there is much informal consultation and communication taking place with residents and relatives each day. PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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. Including neglect and selfharm. The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) People) and 22 (Adults 18-65) 16 (Older Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: Service users and their relatives said they were confident about approaching management and staff with any concern, worry or complaint. They knew they would be taken seriously and that such matters would be acted on appropriately. PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) 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. Shared spaces complement and supplement service users’ individual rooms. Service users have sufficient and suitable lavatories and washing facilities. Provide sufficient privacy and meet their individual needs. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. And lifestyles. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 (Older People) and 24 (Adults 18-65) Service users live in a safe, well-maintained environment. EVIDENCE: A tour of the building showed the home to be well maintained. For example, approximately 10 new windows had been fitted in a rolling programme of improvements. More widows are due to be replaced soon. Repairs to roofs have been carried out. Records of safety checks are maintained. Several bathrooms/shower rooms still require improvement to their ventilation and it is understood that quotations have been obtained. Also, improvements to the second floor call bell system on the Edmondbyers unit are still awaited, so that the room number shows up on the call panel. PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 15 Service users and relatives reported satisfaction with the maintenance of the building and facilities provided. PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 36 (Adults 18-65) are: 27. 28. 29. 30. • • • Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. 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. Service users benefit from clarity of staff roles and responsibilities. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 (Older People) and 34, 35 (Adults 18-65) Staffing numbers, skill-mix and training are good. Arrangements for the recruitment, selection and appointment of staff are sound. EVIDENCE: A staffing review carried out by the provider has led to improvements in staffing levels on the Stanhope Suite. Now, there are 5 care staff and 1 nurse on duty during the day (08.00-20.00) and 2 care staff and 1 nurse at night. The unit manager’s hours are now supernumerary (i.e. not included in the nursing hours provided for direct nursing care). The post-holder is also the Pretoria site deputy manager. Staffing on the Edmondbyers unit is 5 care staff and 1 nurse during the day, and 3 care staff and 1 nurse at night. This latter unit covers 3 floors, whereas the Stanhope Suite covers 2 floors. On the day of inspection, there were 32 service users on the Edmondbyers unit (20 nursing and 12 non-nursing) and 23 on the Stanhope Suite (15 nursing and 8 non-nursing). PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 17 Comments received from service users, relatives, management and staff expressed satisfaction with the current staffing arrangements. Recruitment and selection procedures for new staff are satisfactory, following guidance issued in National Minimum Standards and complying with Regulations. For example, Criminal Record Bureau (CRB)/Protection of Vulnerable Adult (POVA) checks are carried out and references taken up before new staff members are deployed. Staff members confirmed good staff morale and team working. They felt well supported and were receiving supervision and appraisal in accordance with company policy and national guidance. Individual staff training files are maintained. Staff members confirmed that training arrangements were satisfactory. 50 of care staff had achieved NVQ level 2 or higher in March 2005, but that figure has fallen to 40 currently. The home intends to achieve the 50 target later this year. The staff training programme has been comprehensive and relevant to staff training needs. It has included safe handling of medicines, infection control, movement and handling, COSHH, care practice, positive dementia, supervisory development, certificate in safety compliance, first aid, plus peg tubes and nutrition. PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 37 – 43 (Adults 18-65) are: 31. 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 a well run home and from competent and accountable management of the service. 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. Service users are confident their views underpin all self-monitoring, review and development by the home. 32. 33. 34. 35. 36. 37. 38. • The Commission considers standards 33, 35 and 38 (Older People) and Standards 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 (Older People) and 42 (Adults 18-65) The home is run in the best interests of service users and the health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: Service users and relatives commented that their views and opinions were taken into account by the home via formal and informal consultation. They believed the home was very much run in the best interests of service users and was well managed. Communication was described as being good and there was much social involvement of families and friends in the life of the home. PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 19 The findings of quality assurance surveys were being made publicly available in the home. Staff training and supervision was well developed, helping to ensure the health, safety and welfare of service users and staff. Appropriate equipment, aids and adaptations were also evident. Service users and relatives described staff and management as approachable and helpful. Both the registered manager and deputy site manager (unit manager for Stanhope Suite) have achieved the Registered Manager’s Award (RMA) at NVQ level 4. PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 x 3 3 4 x 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 3 x x x x x x x Score Standard No 7 8 9 10 11 Score 4 3 x 3 3 Standard No 27 28 29 30 3 3 3 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 x x MANAGEMENT AND ADMINISTRATION Standard No Score 31 x 32 x 33 4 34 x 35 x 36 x 37 x 38 3 PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 21 Yes Are there any outstanding requirements from the last inspection? 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 YA24 Regulation 23, 13 Requirement Ventilation to some bathrooms and shower rooms needs to improve in the interest of health, safety and welfare; and the call bell system for the second floor on the Edmondbyers unit needs to be upgraded so that the warning panel shows the number of the room calling for assistance. (This requirement is outstanding from the last inspection when the deadline for action was 31/03/05) Timescale for action 01/12/05 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 OP28 Good Practice Recommendations A minimum of 50 of care staff are required to be qualified to NVQ level 2 or above by 2005. PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection No 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 PRETORIA COURT COMPLEX CARE HOME B54 S741 Pretoria Court V228410 110705 Stage 4.doc Version 1.30 Page 23 - 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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