Inspection on 19/12/05 for Pretoria Court Complex Care Home

This inspection was carried out on 19th December 2005.

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 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 11/07/05

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 Pretoria Court Corbridge Road Medomsley Consett Durham DH8 6QY Lead Inspector Mr Stephen Ellis Unannounced Inspection 19th December 2005 1:30 X10029.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 Pretoria Court Complex Care Home DS0000000741.V274250.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 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 DS0000000741.V274250.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pretoria Court Complex Care Home Address 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) Pretoria Court Corbridge Road Medomsley Consett Durham DH8 6QY 01207 561880 01207 563094 Alliance Care (Trendlewood) Limited (wholly owned subsidiary of Four Seasons) Mrs Christine Munro Marr Care Home 91 Category(ies) of Old age, not falling within any other category registration, with number (67), Physical disability (24), Terminally ill (3) of places Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical disability - up to 24 persons with a physical disability (younger adults) may be accommodated in the Stanhope Suite only, commensurate with the home’s statement of purpose. 11th July 2005 Date of last inspection 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 (18-65 years). 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. 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 DS0000000741.V274250.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 4.25 hours. The inspector looked around the building, examined a number of records and spoke with 17 residents, 2 visitors (1 relative and 1 friend) and 6 members of staff (including the registered manager and deputy site manager). What the service does well: What has improved since the last inspection? New floor covering and carpeting has been provided in the dining room and one lounge on the Edmondbyers unit, plus new dining furniture and new sofas and chairs for the lounge and reception area. Another small lounge on this unit has also been redecorated and refurbished. Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 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. Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 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 Outcomes 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, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 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. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) 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. (YA NMS 4) 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 the following 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: Both residents and visitors commented that the needs, aspirations and expectations of service users were being addressed and met, in accordance with their initial assessments carried out prior to admission. An examination of care plans confirmed that this was the case, with full details documented of individual assessments and reviews. Particularly impressive at the last inspection were the memory diaries being created for residents, with the help of residents and families. These helped to express and focus things that were important for the individuals concerned. Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 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 the following standard(s): 7, 8, 9 and 10 (Older People) and 6, 9, 16, 18, 19 and 20 (Adults 18-65). There are very good arrangements for residents’ health, personal and social care. These take into account residents’ physical and emotional needs, plus personal goals where appropriate. People are supported to act independently within a risk assessment framework. There are good arrangements for dealing with medicines. People are treated with respect and their right to privacy is upheld. EVIDENCE: Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 Page 10 Comments received from residents and visitors indicated high levels of satisfaction with the arrangements for health and personal care. For example, one relative said: “The standard of care has been superb…all the staff have been so caring, with empathy and understanding…a very pleasant experience”. Another visitor said: “Whenever we come we find her well cared for, clean, well dressed…she goes out on various outings; she really enjoys it. She’s happy here”. Such comments were typical of those received on the day, and were borne out by the care plans that were impressively detailed, comprehensive and informative about the individuality of the service user and his/her needs. 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. For example, a number of residents had been admitted to the home with very bad pressure sores and/or other serious medical conditions and these have been successfully treated at the home. Such treatment always involves other agencies appropriately. There is good support from primary health care teams and specialist nurses. Linked to this process were the memory diaries that are being compiled for each service user and were last seen by the inspector in July. These were excellent, 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 residents, visitors and staff was evident. Staff members were observed to be courteous, respectful and caring in their relationships with residents. There are good arrangements for the safe administration of medicines. Most residents delegate this responsibility to the home, but they may look after their own medicines, subject to a risk assessment. All nursing staff members have undergone accredited training in medicines and a number of care staff members have done the Safe Handling of Medicines training as well. There is good support from a dedicated Pharmacist who supplies most of the medication in Monitored Dosage form (in blister packs with the medication clearly identified for the individual resident). There are good storage and disposal systems. Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 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. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 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 the following standard(s): 12, 13, 14 and 15 (Older People) and 12, 13, 15 and 17 (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. People are supported to exercise choice and control over their lives. Residents receive a wholesome, appetising choice of menu and enjoy their meals. EVIDENCE: Service users and relatives commented positively on the varied and stimulating programme of social and recreational activities provided. These included residents being involved in making Christmas cards for relatives, pie and peas Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 Page 12 suppers, social evenings, theatre trips (to see productions such as ‘Oliver’), Christmas parties, visiting carol singers from 2 local primary schools, Christmas Fair at the home, shopping trip to ‘Metro Centre’ and visiting entertainers, including a local Brass Band in Christmas week. 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 residents on the Stanhope Suite enjoy a drink, a takeaway meal and/or a film on a Thursday or Friday night in an upstairs lounge. A good number of residents 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. Of particular note at this home is the creation of memory diaries for all residents, which is an ongoing process. These were most impressive when last seen by the inspector in July, using text and photographs and other documents to illustrate the life story and interests of the resident 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, relatives and friends each day. All the residents spoken to said the catering was good. There was a wide choice and the Cook understood their preferences. A cooked breakfast was available for those who wanted one. Residents mainly dined together in one of the two dining rooms. They could, however, eat their meals elsewhere and at different times if required. Records are kept of meals served, available for inspection. The Cook confirmed the varied, appetising menu. There was much emphasis on home baking and fresh preparation of food, such as cakes, tarts and trifles, which were very popular with residents. A choice of two menus, plus alternatives, was always provided. Birthdays were always celebrated with a cake and, sometimes, a special tea if it was a ‘special’ birthday. Residents also have access to a ‘bar’ within the home serving drinks of their choice, including alcohol. Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) 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 the following standard(s): 18 (Older People) and 23 (Adults 18-65). Residents are protected from abuse. EVIDENCE: Pre-employment checks are carried out on staff, including enhanced checks with the Criminal Record Bureau plus Protection of Vulnerable Adult checks. Also, two references are obtained in respect of each new employee, with special attention given to the last employment. This is to try to ensure that unsuitable people are not employed to care for vulnerable adults. New staff members go through induction and foundation training to ensure they have the right knowledge and skills to do their jobs competently. Over the past year, most nursing and care staff members have completed Protection of Vulnerable Adults training, which has been wide-ranging in its coverage of the topic. Residents reported a caring, supportive atmosphere in the home, which is well established. There is good teamwork evident and this reinforces the caring culture and provider policies concerning adult protection. Staff expressed confidence in the manager and senior staff. They would not hesitate to approach them about any suspected abuse or neglect of residents. A comprehensive programme of staff supervision is being conducted. Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 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 live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) 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 the following standard(s): 19 and 26 (Older People) and 24 and 30 (Adults 18-65) Residents live in a safe, well-maintained environment, although there are some estate issues that require further attention. The home is clean, pleasant and hygienic. EVIDENCE: Residents and relatives commented that they were pleased with the material standards of the home, describing it as clean, pleasantly decorated and homely. A tour of the building showed the home to be generally well Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 Page 15 maintained. However, although approximately 10 new windows had been fitted in a rolling programme of improvements earlier this year, most of the remaining widows/window frames still need to be replaced. Repairs to roofs have been carried out. Records of safety checks are maintained. New floor covering and carpeting has been provided in the dining room and one lounge on the Edmondbyers unit, plus new dining furniture and new sofas and chairs for the lounge and reception area. The dining room has also been redecorated. Another small lounge on this unit has been redecorated and refurbished. 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. There were no unpleasant odours and the home was found to be clean in all the areas inspected. Care staff have completed training in Infection Control and, where appropriate, Food Hygiene. Paper towels and liquid soap were provided in toilets and bathrooms in wall-mounted containers, to promote hygienic practices (although residents have personal flannels and towels in their rooms). Some aids and adaptations for disabled people are in place (including adapted telephones, wheelchairs, walking frames, vertical lift and hoists). However, the services and facilities provided should be reassessed to ensure that positive outcomes for all people with disabilities (including sensory disabilities) are being maximised. For example, it is desirable for induction loops to be fitted and TV subtitles to be used for the hearing impaired and for these facilities to be checked and publicised. Stairs are likely to benefit from being fitted with white or yellow edging to aid visual discrimination. It is desirable to have visual fire warning systems, in addition to aural fire alarms, for the hearing impaired. It is desirable to have remote controls for TV etc with large, easy to see and use buttons. Further advice should be sought from occupational therapists and disability advice centres. Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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 and 30 (Older People) and 32, 34 and 35 (Adults 18-65). There are sufficient numbers of staff, with the right skills, for the needs of residents. Residents are in safe hands, although more care staff require NVQ level 2 or above, to confirm competence. The home’s recruitment policy and practices support and protect residents. Staff members are trained and competent to do their jobs, with a full staff-training programme to ensure that the service is able to fulfil its statement of purpose and categories/conditions of registration. 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 Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 Page 17 nursing hours provided for direct nursing care). The post-holder is also the Pretoria site deputy manager. Staffing on the Edmondbyers unit is 4 care staff and 1 nurse during the day, and 3 care staff and 1 nurse at night. At times, an additional carer is needed on this unit due to the current, very high dependency levels of some residents and because the unit covers 3 floors. The manager is trying to secure additional care hours. The home’s registered manager is based on the Edmondbyers unit and her hours are supernumerary as well. Catering and domestic staff members are employed in sufficient number for the current needs of the home. There is a full time administrator and separate, full time maintenance officer on site. On the day of inspection, there were 30 service users on the Edmondbyers unit (19 nursing and 11 nonnursing) and 24 on the Stanhope Suite (16 nursing and 8 non-nursing). Comments received from residents, visitors, management and staff expressed general satisfaction with the current staffing arrangements (although additional care hours are likely to be needed on the Edmonbyers unit). 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. The home’s recruitment policy and practice is sound, ensuring that all preemployment checks are carried out as required, including Criminal Record Bureau enhanced checks and the taking up of two written references. Individual staff-training files are maintained and comprehensive induction and foundation training is provided for all staff. 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 29 currently due to some staff leaving. The home intends to achieve the 50 target during the next 12 – 18 months. 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, control of substances hazardous to health (COSHH), care practice, positive dementia, supervisory development, certificate in safety compliance, first aid, plus peg tubes and nutrition. Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 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. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 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 the following standard(s): 31, 32, 33, 35 and 38 (Older People) and 37, 38, 39 and 42 (Adults 18-65). The manager of the home is fit to be in charge, of good character and able to discharge her responsibilities fully. There is an excellent ethos, leadership and management approach. The home is run in the best interests of residents. Residents’ financial interests are safeguarded in those situations where the home is involved. The health, safety and welfare of residents and staff are promoted and protected. Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 Page 19 EVIDENCE: The registered manager is experienced and competent in her role. Residents, visitors and staff spoke highly of her leadership skills and commitment to good outcomes for residents. She was described as being supportive, approachable and caring. She has achieved the Registered Manager’s Award at NVQ level 4, as has the Deputy site manager. Good accounting procedures are followed, with receipts and signatures being obtained for all financial transactions involving residents’ personal monies, in which the home is involved, wherever practicable. Relatives look after the personal monies of many residents. In those situations where the home helps look after residents’ monies, such as some ‘pocket monies’, clear individual accounts and records are maintained. In practice, residents’ monies in those situations may be kept in one pooled account. However, detailed records of each individual resident’s personal money are maintained and residents and their representatives are informed about this arrangement. Residents have ready access to their monies. This arrangement works well. Comments received from staff and management confirmed that there are good health and safety policies and practices that promote the health, safety and welfare of residents and staff. All staff members do refresher training in Health and Safety, such as moving and handling, fire safety and food hygiene. This helps reinforce the registered provider’s written policies on Health and Safety. Health and Safety issues are also discussed at staff meetings and in individual staff supervision. Residents and staff expressed satisfaction with the way the home was run and the good standards that were evident in many instances. For example, there are residents’ meetings, in which issues of interest and concern are discussed. However, the views of service users about the quality of the services and facilities provided at the home should not only be sought, but the results made public, perhaps by way of newsletter within the home. Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 ENVIRONMENT Standard No Score 19 3 20 x 21 x 22 x 23 x 24 x 25 x 26 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 4 33 3 34 x 35 3 36 x 37 x 38 3 Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 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 two inspections when the deadlines for action were 31/03/05 and 01/12/05.) The programme of widow/window frame replacement needs to be restarted, to ensure residents have full protection from the weather (for example, wind and rain). Timescale for action 01/04/06 2 YA24 23, 13 01/04/06 Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA32 Good Practice Recommendations The home has further to go before it achieves the target of at least 50 of its care staff qualified to National Vocational Qualifications (NVQ) level 2 or above in care (it expects to reach this percentage within the next 12 – 18 months). However, staff training is otherwise good. Some aids and adaptations for disabled people are in place (including adapted telephones, wheelchairs, walking frames, vertical lift and hoists). However, the services and facilities provided should be reassessed to ensure that positive outcomes for all people with disabilities (including sensory disabilities) are being maximised. For example, it is desirable for induction loops to be fitted and TV subtitles to be used for the hearing impaired and for these facilities to be checked and publicised. Stairs are likely to benefit from being fitted with white or yellow edging to aid visual discrimination. It is desirable to have visual fire warning systems, in addition to aural fire alarms, for the hearing impaired. It is desirable to have remote controls for TV etc with large, easy to see and use buttons. Further advice should be sought from occupational therapists and disability advice centres. The views of service users about the quality of the services and facilities provided at the home should not only be sought, but the results made public, perhaps by way of newsletter within the home. 2 YA24 3 YA39 Pretoria Court Complex Care Home DS0000000741.V274250.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Darlington Area Office 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 DS0000000741.V274250.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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