Inspection on 27/02/06 for Pulsford Lodge

This inspection was carried out on 27th February 2006.

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

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

Other inspections for this house

Pulsford Lodge 20/05/08

Pulsford Lodge 14/09/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Pulsford Lodge North Street Wiveliscombe Somerset TA4 2LA Lead Inspector Caroline Baker Unannounced Inspection 27th February 2006 09:35 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.V284644.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. 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.V284644.R01.S.doc Version 5.1 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 39 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. REGISTERED FOR 39 PERSONS IN CATEGORIES OP AND DE (E) Date of last inspection 6th September 2005 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 is undergoing major refurbishment and building work, at this time, and will be increasing the accommodation to provide care for up to 50 service users by end 2006. Pulsford Lodge is registered with the Commission for Social care Inspection to provide personal care to up to 39 people who are over the age of 65, including older people with a dementia. 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. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home’s last inspection was announced and was conducted on 6th September 2005. This unannounced inspection was conducted over one day (15 inspector hrs) by two CSCI Regulation Inspectors - Caroline Baker and Pippa Greed. The registered manager, Sonya Matthias was available throughout the inspection. The majority of the inspection was spent talking with service users and staff, the inspectors were also able to unobtrusively observe staff interactions with service users and join the service users for lunch. Records were examined relating to staff, service users and health and safety. A brief tour of the premises was conducted. The inspector would like to thank the registered manager, staff and service users for their time and cooperation with the inspection process. Not all of the National Minimum Standards were assessed at this inspection and this report should be read in conjunction with the last report. What the service does well: Pulsford Lodge catering provision was exemplary. The feedback from the service users were very positive and highlighted the importance of freshly prepared, appetising meals. Through discussion with service users, and cards shown by the manager, it was evident that complimentary praise was given by service users and their families. These comments focused on the kindness of the staff team. The medication system was organised well and easy to identify. The management and staff team had clear understanding of the service users health needs. The medication system demonstrated good pain control awareness. The laundry facilities were seen on the day by the inspectors. These were viewed to be hygienic, accessible and well organised. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 6 Four service users care plan were seen as part of the case tracking process. The files were clearly written and the service users needs were met through a person centred approach. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. NMS 6 does not apply to this service. The home’s arrangements for ensuring that the home can meet the assessed needs of a prospective service user are very good and the needs and views of existing service users are considered. Service users are issued with a contract of terms and conditions. EVIDENCE: As part of the inspection process four service users were case tracked. This involved assessing their individual care records and meeting with them. There was evidence recorded that the service users had been met prior to admission to ensure the home could meet their individual assessed needs. Pre-admission assessments were comprehensive. Evidence of service users receiving a contract was seen through the case tracking process. Service users and/or their representatives had signed the agreements. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7; 8; 9 and10. Service users benefit from a clear and consistent care planning process, which promotes a person, centred approach. Staffs at the home ensure that service users are treated with respect and that their privacy and dignity is maintained. The home’s procedures for the management and administration of medication are good and protect service users from risk of harm. EVIDENCE: As part of the inspection process four service users were case tracked; this involved meeting the service users and assessing their care records. The care records were found to be well written and detailed for care staff to be able to deliver the care required. They reflected current care needs. Risk assessments were in place in regard to pressure relief, nutritional risks, falls risks and moving and handling. The care plans evidenced service user input. The inspector was able to see that care plans were being reviewed at least monthly. Records were maintained relating to significant daily events. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 10 All service users are registered with a GP and the manager confirmed excellent links and support from the local doctors surgery. District nurses also provide support and advice to the home as required. Service users have access to a visiting dentist and chiropodist. The dentist was visiting the home on the day of the inspection. Care records contain detailed information on the health care needs of service users and a record of all health care professional visits is maintained. The manager confirmed that the home has excellent support and input from the community mental health team. A liaison nurse is allocated to the home and visits on a monthly basis. Evidence was seen in the care plans sampled. All service users spoken with commented on the kindness of staff and confirmed that assistance with personal care was carried out in a manner, which respected their privacy and dignity. Service users confirmed that assistance was provided in accordance with their wishes. The inspector examined the home’s procedures for the management and administration of service users medication. The home uses the Boots Monitored Dosage System (MDS) with pre-printed Medication Administration Records (MAR). A selection of MAR charts was seen as part of the case tracking process and was found to be appropriately completed. Photographs were attached to aid identification. The last pharmacy visit took place on 15th December 2005. To further enhance good medication administration practice, PRN circled on the MAR to distinguish current against PRN medicine. A brief description of each medication purpose would also aid and assist administration. For example - ‘To relieve pain from arthritis.’ All medicines were found to be securely stored and stock levels appeared appropriate. Records and stocks of controlled drugs were checked and were found to be well maintained. Medication is only administered by the senior staffs on duty who have received appropriate training. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13; 14 and 15. The home’s arrangements for ensuring that the expectations and preferences of service users social needs were very good. The standard and choice of food was excellent and service users benefited from a wholesome, freshly prepared, varied menu. EVIDENCE: NMS 12 was not assessed on this occasion. The manager informed the inspectors that since the last inspection the activities co-ordinator had left and that systems had been put into place to ensure that activity provision continues for the service users. Those service users spoken to confirmed this. Service users informed the inspector that they chose how and where to spend their day. This was evident during the inspection. Service users were observed moving freely around the home. For those service users who required assistance to mobilise, staffs were heard to offer choices to service users and assistance were offered in an unhurried and dignified manner. The home places a high emphasis on individual choice and promotes a personcentred approach to care. This is very positive. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 12 In line with their plan of care, service users are encouraged and supported to make decisions or choices even when they may not always be in line with what staff perceive to be in the service users best interests. Links with families and friends is actively encouraged. Minutes of meetings were assessed of those held for families and representatives. Visitors are made to feel welcome at the home. Service users consulted confirmed this. The inspectors were able to join the service users for lunch. The service users were shown consideration by the staff and were given three hot meal choices and six pudding choices. The meals were well presented, appealing and appetising. Many dishes were freshly made. One service user approached an inspector and commented that the food was comparably better than other known day care centres. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home had a satisfactory complaints procedure and service users knew that their concerns would be listened to and acted upon. The home was taking appropriate steps to reduce the risk of harm or abuse to service users. EVIDENCE: The home has a complaints procedure, which is titled ‘Seeking your views’. Copies were seen to be displayed in the reception area. The home had not had any complaints since the last inspection. No concerns or complaints have been received by the CSCI. The home records all compliments received. There had been 88 recorded in the compliment record, all thanking the home for their help and kindness. Service users spoken with informed the inspector that they would not hesitate in raising any concerns with the manager or staff if they had any. The home displays information for service users about independent advocates. The manager confirmed that nobody was using the services of an advocate at this time though assistance would be given to access this where required or requested. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 14 Staff spoken with confirmed that they understood the reporting process for protection and prevention of abuse. This was evidenced through one to one discussion. Through sampling of the recruitment records it was evident that the home followed robust recruitment procedures and staff had undergone enhanced CRB checks and, where appropriate, POVAFirst checks before employment. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19; 21 and 26. Pulsford Lodge provides service users with a safe, comfortable and homely environment. Service users are able to enjoy the privacy of their own bedroom and/or socialise in one of the many communal areas. EVIDENCE: Pulsford Lodge is a purpose built home in Wiveliscombe. Accommodation is on two floors with a passenger lift. The home is presently undergoing major refurbishment programme and building work. There are plans to install a second lift, which will provide ease of access for stretchers and a higher number of wheelchair users. Since the last inspection, several areas of the home have been redecorated. One bedroom has been changed into an assisted bathroom; one bathroom has been changed to a disabled toilet. One bathroom had been converted into a wet shower room promoting ease of access, dignity and privacy. The refurbishment programme will provide further communal bathing facilities. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 16 There are adequate bathrooms and toilets located around the home. The home has many small communal lounges, which have homely atmospheres. There is a dining room that is large enough to accommodate all service users comfortably. All communal areas of the home are attractively decorated with good quality comfortable furnishings. All service users are accommodated in single bedrooms. Bedrooms have lockable storage facilities for service users and all doors are fitted with locks. Service users are encouraged to personalise their rooms. All areas inside the home are accessible to service users with all levels of mobility. Corridors are fitted with handrails to assist service users to maintain their independence. The dining room is fitted with a loop system to assist those service users who have hearing difficulties. A fire detection system and call bells are fitted throughout the home. Hand washing facilities are appropriately sited to reduce the risk of the spread of infection. Extra precautions were implemented by the staff team in the event of infection control. The laundry areas on two floors were seen by the inspectors. The facilities were systematic, clearly coded and hygienic. The laundry room has an internal lift for the transport of clean laundry. All areas seen at the inspection were clean and free from malodours. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27; 29 and 30 Service users benefit from a competent staff team. Staff morale was good. The home followed robust staff recruitment procedures which minimises the risk of harm or abuse to service users. EVIDENCE: Copies of the staff duty rotas were made available to the inspector. These indicated that there were a minimum of 5 care staff on duty between 0730 and 2130hrs. The managers and ancillary staff are in addition to the care hours supplied. Where required, the home uses Somerset Care’s bank staff to cover any shortfalls. The manager stated that the same staffs are used to ensure consistency for service users. Service users met with commented that the care is excellent. ‘We love it here. Everyone is very kind.’ Other comments from service users included; ‘Couldn’t get a better place’, ‘I like staying here – they put us to bed’, ‘It’s like being at home’, ‘Can’t say enough about the staff’. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 18 Service users at the home benefit from a team of staff who have been appropriately trained. Somerset Care actively promotes staff training. Training schedule was seen and all mandatory training was being provided in a timely manner. Samples of staff personnel records provided evidence of relevant trainings given within the induction period. The home follows robust staff recruitment procedures. Recruitment records were examined for two staff employed since the last inspection. All documentation as required in Schedule 2 of the Care Homes Regulations 2001 was available. This included evidence of an enhanced CRB and POVAFirst check. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 38. Service users benefit from a competent and pro-active manager who ensures that the home is run in the best interests of the service users. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. EVIDENCE: The registered manager of the home is Sonya Matthias who has many years experience of working with older people and has managed Pulsford Lodge for about 5 years. She demonstrated in-depth knowledge of individual service users and staff members. The manager has completed the Registered Managers Award (NVQ level 4 in care and management). She has been highly commended by Somerset Care Group. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 20 Staff and service users spoken with spoke highly of the manager and stated that she was very approachable. The manager informed the inspectors that she provides hands on support as well as managerial responsibilities and works shifts to cover sickness when required. Staff and service users consulted indicated that the manager has an excellent awareness and understanding of the assessed needs and preferences of service users living at the home. The inspectors were able to view samples of compliment cards, which emphasised the families’ views and satisfaction. All records requested by the inspector were made available. All records seen were well maintained, up to date and stored in accordance with the Data Protection Act 1998. At the time of this inspection, the home was taking appropriate steps to ensure the health and safety of service users, staff and visitors to the home. This was ascertained by a tour of the premises, on discussion with staff and on examination of the following records: FIRE SAFETY – The emergency lighting were last checked on 08/02/06 ELECTRICAL SAFETY – The home’s portable appliances (PAT) are tested annually. This was last carried out during October 2005. The home has an up to date electrical hardwiring certificate, which was completed on 06/12/05. GAS SAFETY – The home’s last annual gas safety check was conducted on 18/11/05. ACCIDENTS – The home maintains appropriate records for all accidents. All accident records were seen to be appropriately stored in accordance with the Data Protection Act 1998. The manager analyses accidents monthly and takes appropriate action where required. 109 were recorded since August 2005. 61 of those at night-time. All audited by the manager and appropriate actions were taken. Falls summaries were evidenced in case tracked files. The manager informed the inspector that any re-occurring falls would be referred to a Falls Rehabilitation team. HOT WATER OUTLETS/SURFACES – The home maintains records of weekly checks on all hot water outlets. Records seen indicated that bath hot water outlets were within HSE recommended limits. To reduce the risk of injury to service users, all bath hot water outlets have been fitted with thermostatic controls. Warning signage is displayed on all wash hand basins. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 21 The home carries out weekly checks to ensure the prevention of legionella. This involves running taps and soaking showerheads. This was last checked on 22/02/06. Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A 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 X 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X X X X X X 3 Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? NA. 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. Refer to Standard Good Practice Recommendations Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Pulsford Lodge DS0000016051.V284644.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!