Inspection on 20/05/08 for Pulsford Lodge

This inspection was carried out on 20th May 2008.

CSCI found this care home to be providing an Excellent service.

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

Pulsford Lodge 14/09/06

Pulsford Lodge 27/02/06

Pulsford Lodge 06/09/05

Pulsford Lodge 22/02/05

Pulsford Lodge 27/07/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Pulsford Lodge North Street Wiveliscombe Somerset TA4 2LA Lead Inspector Gail Richardson Unannounced Inspection 20th May 2008 09:45a 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 Pulsford Lodge DS0000016051.V360610.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. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pulsford Lodge Address North Street Wiveliscombe Somerset TA4 2LA 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) 01984 623569 01984 624766 sonya.matthias@somersetcare.co.uk Somerset Care Limited Mrs Sonya Elizabeth Matthias Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 50. 14th September 2006 Date of last inspection Brief Description of the Service: Pulsford Lodge is situated in the heart of the small town of Wiveliscombe. All local amenities are within a short walk and the home benefits from views over the surrounding countryside. The home was purpose built in the 1970s. The home is very much part of the local community and enjoys good relationships with local professionals. The home is set on two floors with a passenger lift large enough to accommodate wheelchairs, all internal areas are accessible to people who have mobility difficulties. The home has increased the accommodation available to provide care for up to 50 service users over the age of 65 with personal care needs only. The home is not registered to provide nursing care. The home is owned by Somerset Care Ltd. The registered manager is Sonya Matthias, and the responsible person is Marion Osborn. The current free range is between £390.00 and £580.00 with further charges made for items such as hairdressing, chiropody and some outside activities Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This was an unannounced inspection, which took place over 1 day (7 hours) on the 20th May 2008 by Regulation Inspector Gail Richardson. A tour of the home took place and a selection of the bedrooms and all communal areas were seen. There were 36 people currently residing at the home receiving personal care. There were no people receiving respite care at the time of inspection with one planned respite discharge due on the day of inspection. The inspector spoke to 9 people using the service and 10 members of staff, the Registered Manager was available throughout most of the inspection. The home has provided CSCI with a completed AQAA (Annual Quality Assurance Audit), which was completed by the Manager, and gives details of all aspects of the home, sections of this document are used within this report. As part of this inspection the inspector surveyed the opinions of a random selection of people using the service and their representatives, GP’s, District Nurses and Care Workers, good levels of responses were received. The inspector spent time talking to people within the home and staff and observed that on the day of inspection, residents appeared comfortable in all areas of the home. It was evident from this observation that the people looked well cared for. All people using the service spoken to, and who were able, spoke of the managers and staff member’s kindness and support. Records relating to care including 6 care plans, 2 staff files, finances and health and safety records were examined The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 6 What the service does well: Comments received from surveys were very positive in their appreciation of the management and staff at the home. Many commented on the improvements seen in quality of life since admission to Pulsford Lodge. These comments included; ‘The care staff and all other staff could not be better’ ‘They look after my relative like I would at home, my relative has never been happier, my relative always says they spoil them even down to the cook and all the staffs children always speak to the residents when they come in, its just one big happy family’ ‘I couldn’t wish for my relative to be in a better care home’ ‘Excellent leadership from the nurse manager who combines efficient business like approach with a very caring loving attitude’ ‘They care for the residents, always listen and help in any way’ ‘It combats the feeling of loneliness. The atmosphere of this home is wonderful, people appear to be happy in their work and this makes the users feel more confident and happy. Care is taken to make my relative feel wanted’ Staff surveys were all positive about the experience of working at Pulsford lodge. Staff comments included ; ‘This is their Home.’ ‘We care for the needs of the individual service user and accommodate friends and family.’ ‘We provide a clean, safe, relaxed environment for our clients to feel at home.’ We are ‘Friendly hardworking, loyal staff, supportive management, good food, good community links’. ‘I think Pulsford lodge is a well run and very happy home, all the staff are friendly and happy and this makes for happy service users’ The manager ensures that nobody moves to the home unless they have been appropriately assessed. People are also encouraged to spend time at the home before making a decision to move there. This ensures that all parties are happy that individuals assessed needs and aspirations can be fully met by the home. The home’s computer care planning systems are regularly updated. Staff are fully aware of peoples’ assessed needs and preferences. People living at the home confirmed that staff knew what they liked and that they are involved in regular reviews. Appropriate procedures are followed for the management and administration of peoples’ medication. All staff have received appropriate training to ensure the safety of medication practice. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 7 People told us the food was very good and that there was always a good choice and plenty to eat. We were able to see that people are involved in menu planning to ensure that their choice and preferences were included. The home responds well to concerns and all surveys and discussions at inspection confirmed a positive response to any concerns raised. Communication links between the home and relatives/ representatives and visiting health professionals would appear to be good and provides a good level of support to people using the service. Following discussion with people using the service and information from surveys received the activity provision was confirmed to be varied and person centred. The building works undertaken to increase the homes capacity to 50 places is now complete. The standard of décor and furnishings is of a very good standard and a well equipped activity room, reminiscence room and sewing room is commendable. The garden area is easily accessible and has been well adapted to meet the needs of older people and for those with mobility difficulties. Staff receive appropriate induction and good levels of training to ensure that they can provide the care needed. Staff recruitment protects people from the risk of harm by ensuring that all appropriate checks are made prior to prospective staff commencing employment People benefit from a very effective and proactive management team, which consists of the homes manager, and a clearly organised staff team. The home follows the correct procedures relating to health and safety. The home’s infection control procedures are good. What has improved since the last inspection? No requirements were made at the previous inspection; good practice recommendations were made regarding the recording of activities. Activity recording is now undertaken in more detail and the information is used to inform activity planning for each person. A good practice recommendation was made to provide staff training in dementia care, this has been undertaken. A good practice recommendation was made to ensure that all staff received regular supervision; this was seen to have been undertaken. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 8 The home has completed an extensive building programme to increase the capacity of the home to 50 residents. At registration of the new building the home changed its registration to include people using the service with personal care needs only and the home is no longer registered to admit people with dementia care needs. The environment of the home continues to be refurbished in a rolling program of re decoration. 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. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 9 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 Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 10 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): 1 2 3 4 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home ensures that people are only offered a placement once all parties are satisfied that the individuals needs and aspirations can be met. People are encouraged to visit the home on more than one occasion before making a decision to move there. The home ensures that staff have the skills needed to meet the needs of people living there. EVIDENCE: The home have produced a Statement of Purpose and Service User Guide which detail information about the home and services offered. We were not informed of any changes to these documents since the previous inspection. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 11 At this inspection we were able to see evidence that people are appropriately assessed by the home before a placement is offered. The home completes a detailed pre-admission assessment to ensure that the home is able to fully meet the individuals needs and wishes. Assessments from other healthcare professionals are obtained where available. The homes Annual Quality Assessment Audit states :’Service users are assessed before they are admitted to the home, they are given a brochure, Service User Guide which includes information on ‘Seeking your Views.’ On visiting the home they are invited to look at our Statement of Purpose. - We actively encourage prospective service users and their families to visit us. Prospective service users are encouraged to stay for a meal, try some day care, have a respite stay even if it’s only a weekend and encouraged ask questions. We also visit prospective service users in their own homes and hospital and by using a combination of asking questions, observation, family input and liaising with fellow professionals by way of the Single Assessment Process we are better able to make an informed assessment of prospective service users needs to determine if we are able to fulfil the persons expectations and requirements. As part of this process we are conscious of considering the implications on our current service users and their needs’’ Evidence seen at inspection would support this statement. 19 Residents surveys received stated that all 17 had received a contract and all felt they had received enough information prior to admission, about the home to make an informed decision. The contract of terms and conditions or residency was examined and found to contain the appropriate information required. Comments received included. ‘I came I day a week for day care before I came in permanently’ ‘My daughter inspected this care home and gave it a good report’ ‘I talked to the doctor, family and social worker’ ‘Visited twice had long chats with Sonia’ ‘Had a guided tour of the home, my son and I were offered lunch which we both enjoyed’ The home has been suitably designed and adapted to meet the needs of older people with grab rails, ramps and a range of other equipment is available in the home which helps to promote mobility and independence. The registered person is committed to ensuring that staff have the skills needed to meet the needs of people living at the home. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 12 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 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home’s care planning procedures are very detailed and staff and people using the service input promote a person centred approach to care planning. The home takes appropriate steps to ensure that peoples’ healthcare needs are met. Staff ensure that people living at the home are treated with respect. The home’s procedures for the management and administration of medication are good. EVIDENCE: The homes Annual Quality Assurance Audit (AQAA) states All our service users benefit from a consistant care planning process which promotes a person centered approach which is set out in an individual care plan. Care plans are detailed, reflect current personal and social needs. Risk assessments are in place regarding pressure relief, nutritional risks, falls risks, Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 13 moving and handling and self medication. Service users have input into their care plans. Service users care needs are reviewed at least monthly.. Input from fellow professionals is ongoing, we have strong working partnerships with our local GPs, District Nurses, CPN and Rehab Team. We are able to refer directly to the area Rehab Team which ensures a prompt service with a team who are familiar with the home and our service users. Evidence seen at inspection would support this statement. At this inspection we looked at 6 care plans using the homes computerised care planning system. These were found to be fully completed and up to date. Assessed needs were clearly identified and instructions for staff gave clear information on how these needs should be met. The preferences of each individual had also been recorded. This included preferred times for waking or retiring to bed, bathing preferences and dietary preferences. Assessments relating to moving and handling needs, nutrition and levels of dependency were in place. Environmental risk assessments were also seen. We were able to see evidence that care plans were being reviewed at least monthly. People who had specific needs relating to wound care had the regular input of the visiting District Nurse and the home has regular input from a visiting Community Psychiatric Nurse. Each care plan contained a ‘social history’, which gave good information about the persons life history and past hobbies. Staff commented that communication systems are very good with sufficient handover time being available and good systems in place to communicate any changes to people using the service and their relatives/ representatives. Comments included ‘We use the computer to pass on messages to other staff if we do not see them on a daily basis. Senior staff pass on information daily to all members of staff.’ ‘New information is given at handovers and are put into care plans straight away’ ‘There is always plenty of information in the care plans’ The home weighs each person on a monthly basis. Records are maintained so that any significant changes in weight can be highlighted. Hard copy care plans were also available and were updated monthly to ensure that should the system cease to be accessible staff could refer to an updated document. Discussion with staff confirmed that care plans are a working document and are accessed and updated by all staff. All staff had received appropriate computer training and staff explained that as part of the induction process staff had access to a laptop care plan simulator for practice. The registered person confirmed that the home had very good links and support from appropriate healthcare professionals. Local G.P and CPN are utilised and visits are made to the home by a chiropodist and optician. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 14 Care plans viewed contained details of each persons contact with a healthcare professional. Surveys from visiting health professionals commented that there was; ‘Effective communication between home and GP’ ‘Sonia and the staff are very accommodating and will try to work with me with difficult clients. They also acknowledge when they lack skills required for those difficult clients. We have a very good working relationship’. When asked do you receive the care and support you need, 19 surveys said always, all 18 responded that staff listen and act on what the residents say. Comments received from people using the service included ‘Girls are very good to me, always make sure I have what I require’ ‘I have been well looked after’ ‘I feel that I always receive good care from all of the staff. ‘’ ‘The staff spend a lot of time listening and doing what I ask of them’ ‘Carers are all so kind and well trained, they know what they are doing I am very happy here, everyone is happy and it feels like home’ ‘Care is given with thoughtfulness’ ‘Pulsford lodge is a very caring and loving place to be-I thank God.’ ‘The staff are very easy to talk to, they are wonderful and so kind, I am very happy here’ Relative comments included; ‘I live away from the area and have e-mailed or phoned about any problems’ ‘I am regularly informed of my relatives progress and needs’ ‘Cant fault the care and attention given the staff are simply wonderful’ ‘The patients phone is often busy unsurprisingly, it is always possible to leave a message’ ‘As soon as resident needs a doctor we are told when the doctor has been and told what is wrong, information is spot on’ ‘I am always consulted in issues requiring a decision’ ‘My relative is spoilt out at Pulsford’ The medication systems appeared to be managed to a good standard. The home has written protocols in place on the Medication Administration Records for the administration of most medications. There were no gaps evident in the Medication Administration Records and the home audits of the medication records and action is taken for any gaps noted. There was evidence of variable doses being recorded and hand transcribed entries being signed by 2 staff. People using the service have the option to self medicate should they want to and risk assessments are in place to ensure safe practice is maintained. Lockable storage is available as required. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 15 A homely remedy policy is in place with signed consent on agreed protocols by the relevant GP’s. The application of prescribed creams is recorded in the care plan. Feedback to the manager included advice that the names of creams should always be specified together with the place of application. All medications were stored safely and securely with systems in place for ordering and disposal. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 16 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 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are supported to live a flexible lifestyle and the home provides opportunities for social/recreational stimulation which reflects their varied interests and abilities. People using the service are actively encouraged to be in control of their lives and to maintain contact with family and friends living in the community. People benefit from a wholesome and varied menu and the home ensures that the meals offered are in line with their preferences. EVIDENCE: Care plans contained good information about the social history and hobbies/preferences of people living at the home. Staff maintain a record of all activities offered in each persons plan of care. The home employs activity staff who co ordinate in house activities and trips out. On the day of inspection there was a mini bus trip out for afternoon tea for 13 people including 2 people in wheelchairs and 4 staff. Information about activities is clearly displayed for people in the dining area and people using the Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 17 service explained that the choice of people on the trips is rotated. All trips out are supported by suitably first aid trained staff. During this inspection we spoke to people living at home who confirmed that activities take place mid week and that they have a choice if they wish to participate. They told us that they enjoyed the activities available. Resident’s surveys asked are there activities arranged by the home that you can take part in, 10 -always,8 usually, 1 -sometimes. The home has a well-equipped activity room providing a range of traditional and electronic games. People using the service told the inspector that they enjoyed the slide shows and other activities taking place in the activity room. The home also has a reminiscence room which people are free to visit and promotes discussion and reminiscence. There is also a sewing room available and a mobile shop selling sweets and toiletries. The home has a fully equipped hairdressing salon with waiting room. Visiting hairdressers have access to this facility enabling people to continue using the hairdresser of their choice. People using the service informed the inspector that the waiting room is very social event with coffee served and is an opportunity to catch up with other people using the service. Some people chose to spend time in the privacy of their own rooms and others were seen in the various lounge areas. Kitchen facilities are available throughout the home to enable people to make themselves a drink. The homes Annual Quality Assurance Audit (AQAA) states Residents have a lovely new courtyard garden and many have spent time with the Manager, staff and the cat - preparing pots and planting out bedding plants. Residents have chosen the plants they wish to pot up and some residents make sure the pots are watered and weed free. The garden area is attractive and landscaped to ensure easy access for people using the service. People confirmed that the area is well used. Staff and people using the service are currently having a plant growing competition. Comments from people using the service included; ‘Every weekday activities available’ ‘I attend Church service’ ‘We have some very nice outings’ ‘I do not usually partake in group activities which are available. I am a very private person so I prefer doing things like helping the girls lay up the tables so I can sit and have a chat with someone’ ‘We have fun and variety’ ‘The activities are very varied to suit residents of different abilities’ One relative commented that they would like ‘More activities at weekends ‘ and another commented that Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 18 ‘They only occur in the mornings and week to week they are similar or the same’ Several people using the service explained that they are supported to walk into the nearby village to visit relatives and friends and visitors were seen at the home throughout the day. In line with fire regulations, all visitors to the home are required to sign the visitor’s book on arrival at the home and before leaving. Relative surveys asked if the home helps their relative to keep in touch 8always and 3 – usually Resident’s surveys asked if residents like the meals at the home, 12-always, 6usually, 1- sometimes. Copies of menus were made available at this inspection and people using the service confirmed that people are encouraged to influence what food/meals are offered. Recent quality assurance had raised issues around vegetable preference, which had been reflected in the menu planning. People spoken with were very positive about the food at the home; On the day of this inspection the lunch consisted of roast chicken, stuffing, roast potatoes, vegetables and gravy or vegetable cobbler. Vegetables were provided in serving dishes to encourage individual choice. Each table was also offered extra vegetables which has been kept hot. Four puddings were available and people were also offered coffee or tea to finish their meal. The inspector participated in the dining experience and found that the lunchtime meal was appetising and plentiful. The atmosphere was calm and sociable, people who required assistance by staff were supported in a discreet manner. People told the inspector that all meals are available in the dining room but should you request it your meal could be served in your bedroom. Comments received from surveys included; ‘Alternative food always available, if I don’t like what’s on the menu’ ‘I am a small eater but do enjoy what I choose’ ‘I enjoy the meals and we have a say in the menus’ ‘If I have a personal dislike for a particular item, the chef will always provide an alternative’ ‘Sometimes choice or lack of it in the dining room leaves some room for improvement’ ‘As a whole the food is good’ ‘The meals in the dining room are exceptional’ Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 19 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 17 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has appropriate systems in place to enable people to raise concerns. People using the service and staff are confident in the management of the home to address any concerns The home takes appropriate steps to reduce the risk of harm or abuse to people living at the home. EVIDENCE: The home displays a complaints procedure within the home. ‘Seeking Your Views’ is displayed on the resident’s notice board, a copy is in the Statement of Purpose and a further copy is contained in the Service User Guide. We were advised that the home had not received any complaints since the last inspection and CSCI has not received any complaints about this service. The homes Annual Quality Assurance Audit (AQAA) states Pulsford Lodge takes any and every complaint seriously. Complaints are investigated thoroughly following SCL company policy relating to Complaints and Protection with in the laid down timescale. Staff and people living at the home confirmed that they would feel confident in raising concerns, if they had any, with the manager or staff on duty. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 20 Staff comments included ‘The home deals with concerns straight away, refer to the manager’ Staff training records indicated that staff had received training in the protection of vulnerable adults, Staff confirmed that training in adult protection is ongoing. Staff spoken with confirmed that they were aware of the complaints policy and ‘whistle blowing policy’ and were able to explain to the inspector the process to be undertaken should an allegation of abuse be made. The home has an up to date copy of Somerset’s Safeguarding Adults Policy (May 2007). Comments received from people using the service included; ‘Manager and staff always on hand to solve any problems’ ‘See the supervisor or manager’ ‘Supervisor are always available to help and Sonia is always around to listen and help’ ‘Everybody listens, Sonia is happy to sort things out for me’ All people using the service are registered to vote in future elections. People using the service have access to independent advocacy services and befriended services. The home has policies for staff, which preclude them from accepting gifts, benefiting from a will or being involved in drawing up a will. All potential staff are CRB (Criminal Record Bureau)/POVA (Protection of Vulnerable Adults) checked prior to commencing employment. Training regarding vulnerable adults and abuse is part of the induction process, the NVQ process and annually thereafter. All 14 relatives surveys and 17 people using the service surveys, confirmed that they knew how to make a complaint and surveys confirmed that people knew who to speak to if they were unhappy. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 21 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 20 21 22 23 24 25 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home, including bedrooms, communal areas, bathrooms and outdoor areas are maintained and furnished to a very good standard People have access to a range of aids and adaptations which help to maximise their independence. The standard of cleanliness is very good and appropriate steps are in place to reduce the risk of the spread of infection. EVIDENCE: The homes Annual Quality Assurance Audit (AQAA) states The major building works are now complete and life returns to some normality. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 22 Refurbishment is taking place in the original part of the home but at a much more leisurely rate, two rooms at a time are being refurbished with very little disruption to residents. Original toilets are to be upgraded and redecorated, the upstairs decommisioned bathroom is to be refurbished and will become an additional shower room. The original wing corridors have been redecorated and recarpeted. Our home has increased in size but we have managed to keep Pulsfords homely atmosphere. Residents now have the choice of 7 lounges and 3 quiet areas where they can sit and read a paper, have a cup of coffee with family or friends, do the crossword or just relax or reflect with out having to stay in their rooms. A wide selection of bedrooms and all communal areas were viewed during this inspection. It was apparent that people are encouraged to personalise their rooms and small pieces of personal furniture were evident. Most rooms have en-suite facilities and no rooms are shared. The standard of furnishings, fixtures and décor in bedrooms and en-suites were of a very high standard. One person explained that their room was to be refurbished and they would be temporarily using a new room, which they then had an option to remain in. They had been involved in the choice of colour of the redecoration. It was observed that 1 window on the upper floor was not restricted. The manager arranged at inspection for this to be reviewed and a letter to CSCI confirming repair was received within 4 days. A further unrestricted window has since been restricted and a risk assessment put in place. The gardens are well maintained and accessible (see standard 12). There is a range of bathrooms and toilet facilities with equipment for bathing either assisted or unassisted is available to support people with personal hygiene. Specialist equipment was seen where there was an assessed need and this was reflected within each persons care plan. . Hot water outlets are fitted with thermostats to ensure that they do not exceed the Health & Safety Executive recommended upper limits. Outlets checked at this inspection were not within recommended limits. Some sink hot water outlets were noted to exceed the recommended temperature of 43 degrees. Signage was placed at each sink to explain that the water was hot .The manager explained that a new boiler had been fitted , she arranged on the day of inspection for an engineer to visit to adjust the temperature. A further letter to CSCI confirming the adjustment of thermostats was received within 4 days. 18 residents surveys confirmed that the home is always clean and fresh. The home takes appropriate steps to reduce the risk of the spread of infection. Liquid soap and paper towels are appropriately sited and staff have access to a good supply of disposable gloves and aprons. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 23 Comments included ‘Home clean and fresh ?100 ’ ‘Cleaning staff work very hard’ ‘I would like to see male only and female only toilets’ Relatives commented : ‘Home spotlessly clean’ ‘Its always clean and welcoming’ ‘The overall decorative appearance is exceptional’ ‘It is spotless’ ‘It would be nice if residents could sit in the very nice gardens rather than the entrance’ ‘No smells, my family comment of this’ The home’s laundry area appeared clean and well organised. No concerns regarding infection control were noted. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 24 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 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are appropriate to meet the needs and number of people currently living at the home. The home ensures that staff have the skills and training needed to meet the needs of the individuals. Training is ongoing for all staff. The home follows satisfactory staff recruitment procedures. EVIDENCE: The homes Annual Quality Assurance Audit (AQAA) states We follow a robust recruitment procedure following regulatory and SCL polices, ensuring all checks are made. We are at present actively recruiting to ensure new members of staff are in place before our numbers of residents increase. We endeavour to maintain a well balanced mix of staff who are well trained and able to meet the needs of our service users. All staff receive mandatory training. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 25 We actively promote training and give a comprehensive Induction following Common Induction Standards. Recruitmet has proved difficult mainly due to our location, therefore we have been mindful not to increase occupancy until we have the right staff in place. We have bank staff from the SCL Bank Scheme and Newcross agency. We are fortunate that be have received continuity of the same staff from both of these providers. Resident’s surveys asked if staff were available when you need them said, 13always, 6.-usually. Relatives surveys were asked ,do staff have skills and experience to care properly? Responses are 11-Always,3- usually. On the day of inspection there were 6 care staff on duty with the registered manager. Further staff included 1 administrative staff, 3 domestic staff,1 handy man and 1 activity staff. There is 6 care staff on duty in the afternoon and 3 waking staff on overnight. At inspection, people indicated that their needs were met and staff stated that they experienced no problems in meeting peoples assessed needs with the number of staff on duty. However some survey comments from staff stated that; ‘Work can be a bit harder when we loose staff and new staff are on shadow shifts, but on the whole everything runs well’ ‘The staffing includes agency at present, we always have enough staff on but we have to use agency regularly due to expansion and vacancies’ ‘Could improve by: Slightly better pay so that we can keep existing staff and keep staffing levels up so we don’t need to use so many agency staff’ ‘I think more time all round the staff would be much better for the service users and staff to do a better job.’ ‘We have a brilliant team here and that counts for a lot’ The manager explained that staffing levels currently exceed the dependency level for the number of people living at the home. People using the service comments included; ‘I also feel that the girls are so busy sometimes I hesitate to ring the bell so I try and manage myself’ ‘Staff are lovely, need more of them’ ‘I feel that the home needs more staff as current members are all so busy when on shift’ ‘Staff are always efficient and kind’ ‘Staff are very nice’ ‘Somebody is always available if you need them. All staff members are always free to help me especially through this difficult time in my life’ Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 26 We were informed that 78 have achieved a minimum of an NVQ Level 2 in Care. This exceeds the 50 recommended in the National Minimum Standards. Records confirmed that mandatory training is maintained for all staff and that further training is encouraged. The home has a qualified first aid staff member on each shift. Staff commented that; ‘I have been on numerous courses to do with activities and also attended courses to do with the care of service user such as Manual handling, Dementia, Abuse, Fire Training etc.’ ‘I have regular training at Pulsford and I attend courses at our training centre in Taunton’ ‘We receive statutory training and also Sonia gives us some choice. I have attended a lot of training ‘ ‘Somerset care is an excellent company for training from in house statutory training to management raining covering lots of topics, abuse, mental health’ ‘We receive regular supervisions, individual and group and yearly appraisals’ We were able to see that staff follow an appropriate induction programme on commencement of employment. The manager stated that newly appointed staff are provided with an induction workbook which is in line with the Skills for Care 12 week Common Induction Standards. One staff commented; ‘I felt the induction was full, plenty of ongoing support afterwards as well. I was made to feel very welcome and the support I was given was brilliant.’ We looked at the home’s procedures for staff recruitment and examined 2 staff files. There was evidence that the home obtains all required information including a Criminal Records Check (CRB) and Protection of Vulnerable Adults Check (POVA) prior to commencing employment. The recruitment systems are robust and all procedures followed ensure that the people using the service are protected from the risk of abuse. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 27 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 32 33 35 36 37 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from an effective manager who promotes an open and inclusive style of management where views of people using the service and staff are listened too and valued. The home has an effective quality assurance programme in place, which seeks the views of persons at the home and their relatives/representatives. There is evidence that changes are made based on the views of the people living at the home. Management of personal monies is satisfactory. Personal records are stored securely in line with the Data Protection Act. Staff are appropriately supervised. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 28 EVIDENCE: The homes Annual Quality Assurance Audit (AQAA) states Sonya Matthias, the Registered Manager has a level 4 Registered Managers Award and has many years experience of working with older people. She has managed Pulsford Lodge for 7 years. Sonya updates her knowledge and has attended all mandatory training along with a Management Development Programme supported by Somerset Care Ltd. Comments received from people using the service, relatives , visiting health professionals and staff are highly complimentary about the management style and support they receive from the manager. Comments included; ‘The manager is always very helpful with anything to do with my role and always has time for me if I have any problems she is always there to give advice.’ ‘We have regular conversations with our manager and also we are asked if we have any problems. I know her door is always open to me.’ ‘Sonya has regular staff meetings and we also have regular supervisions and annual appraisals’ ‘Sonya is very professional experienced manager who runs a solid home, while keeping a relaxed atmosphere’ The homes Annual Quality Assurance Audit (AQAA) states Quality Assurance and monitoring systems are in place, regular auditing of falls, medication, care needs, water temperatures, finance, residents/relatives surveys, training evaluation,Inspections from EHO/Pharmacist/CSCI etc. Surveys are made available for current and prospective service users. The home has a quality assurance programme in place. Comments are sought from people using the service and their representatives on an annual basis. Comment cards have sent out and the information received used to change practice at the home to support the choices and preferences of people using the service. The homes Annual Quality Assurance Audit (AQAA) states Residents are encouraged to control their own finances, many families assist residents with this. Some money is held in the homes safe for some residents and each resident has their own record of transactions which contain the balance of the account, receipts, a balance sheet which is doubly signed. The balance of each account is audited monthly. Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 29 Systems for managing personal monies were examined and found to be satisfactory The home has systems in place to ensure that staff receive formal supervision sessions at least six times a year. Documented evidence of this was made available to us at this inspection. All records relating to the people using the service are stored securely in line with the Data Protection Act The home maintains records for all accidents. Records were examined and were found to be reviewed monthly and appropriate action including risk assessments and changes in care recorded in the persons individual care plan. As required in the Care Homes Regulations, the manager informs the Commission of any death or significant event at the home. The home has completed a fire risk assessment dated 28/02/08. This is to conform to The Regulatory Reform (Fire Safety) Order 2005, which was effective from 1st October 2006. We were able to see that the home conducts weekly in-house checks on the home’s fire detection systems and monthly checks on the emergency lighting with an annual service of emergency lighting on 05/11/07. Annual servicing by external contractors was up to date. Staff training records indicated that all staff had received fire-training on14/05/08. We were able to see evidence that annual testing on portable appliances was up to date. Records indicated that testing last took place on 25/05/08. The registered person is required to ensure that all portable appliances are checked in accordance with, and at frequencies determined by, the Health & Safety Executive (HSE). The person conducting the checks should be deemed competent and records must be maintained. The hardwiring certificate had been completed on 06/12/05 and was in place for 5 years Gas service records showed that the gas system had been serviced on 01/01/08 and boiler service records confirmed service on 24/04/08. The nurse call bell system had been serviced on 29/04/08 and the lift was last serviced on 12/11/07. All hoists and lifting equipment had been serviced on 08/04/08 Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 3 3 3 Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 31 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. 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 OP12 Good Practice Recommendations The manager is recommended to ensure that any prescribed creams are recorded in the care plans to include the name of the cream and the details of where it is applied Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Pulsford Lodge DS0000016051.V360610.R01.S.doc Version 5.2 Page 33 - 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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