Inspection on 06/09/05 for Pulsford Lodge

This inspection was carried out on 6th September 2005.

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

The inspector 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 27/02/06

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 Kathy McCluskey Announced 6 September 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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 D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Pulsford Lodge Address North Street, Wiveliscombe, Somerset, TA1 2PX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01984 623569 01984 624766 Somerset Care Ltd Mrs Sonya Elizabeth Matthias Care home only 39 Category(ies) of Dementia - over 65 (39) registration, with number Old Age (39) of places Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Registered for 39 persons in categories OP and DE (E). Date of last inspection 22nd February 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 1970’s. The home is very much part of the local community and enjoys good relationships with local professionals. All accommodation is well maintained and homely in appearance. 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. 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 can only physically accommodate 37 service users. 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 D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home’s last inspection was unannounced and was conducted on 22nd February 2005. One recommendation was raised. This announced inspection was conducted over one day (6.5hrs) by CSCI Regulation Inspector Kathy McCluskey. The registered manager, Sonya Matthias was available throughout the inspection. The majority of the inspection was spent talking with service users and staff, the inspector was also able to unobtrusively observe staff interactions with service users. Records were examined relating to staff, service users and health and safety. The registered manager provided the CSCI with a detailed and informative preinspection questionnaire. CSCI comment cards were sent out to 10 service users and health care professionals. After discussion with the manager, it was agreed that for future announced inspections, the CSCI would provide comment cards for all service users. A 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. This was a very positive inspection. No requirements or recommendations were raised. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 6 What the service does well: Pulsford Lodge provides service users with a safe, comfortable and homely environment. The home has appropriate aids, adaptations and specialist equipment available to ensure that the assessed needs of service users can be met. Service users benefit from a manager who is experienced, well trained and is committed to ensuring that the needs and wishes of service users are met. Service users benefit from a staff team who are well trained and well informed as to the needs and preferences of service users. Staff morale is high and this has a positive outcome for service users. Without exception, all service users spoken with commented on the kindness of staff. Some comments received included; ‘ you never feel rushed by staff’ and that staff ‘would do anything for you’. Other comments from service users included; ‘Staff are wonderful’, ‘They always have a laugh and joke with you’, ‘Nothing is too much trouble’, ‘they will do anything to help you’. The inspector observed staff interactions with service users. These were noted to be kind and respectful. Without exception, all service users spoken with stated that they felt safe and well cared for at Pulsford Lodge. The overall atmosphere in the home was very relaxed and comfortable. The home has established excellent links with health care professionals. Service users have access to all health care professionals as required. G.P’s, dentist, chiropodist and mental health professionals visit the home on a regular basis. Very positive comments were received from service users regarding the food available at the home. Choices are always available. Service users choose where to have their meals. Snacks and drinks are always made available. The home has established excellent links with the local community and service users are able to benefit from this. Service users were very positive about the range of activities available to them. Service users benefit from regular trips out. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. The home takes appropriate steps to reduce the risk of harm or abuse to service users. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 7 Several of the National Minimum Standards have been exceeded by the home. 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 D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 9 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 standard(s) 1, 3, 4 and 5 Standard 6 is not applicable as the home is not registered to provide intermediate care. Prospective service users are provided with the information they need to enable them to make an informed choice about moving to the home. 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. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide. These are made available to service users, prospective service users and their representatives. The home’s Statement of Purpose was seen clearly displayed in the reception area of the home. This included copies of the last inspection report. The home produces a newsletter called the ‘Pulsford Prattle’. This is a more informal way of sharing information about the home. A copy was made Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 10 available to the inspector and it was seen to contain ‘lively’ and very interesting news, activities and planned events. A copy was also available in the reception area. The inspector was informed that the Statement of Purpose has been updated since the last inspection. The home’s current fee range is between £349 and £450 per week. Additional charges are met by service users for Chiropody, hairdressing, toiletries and newspapers. Prospective service users and/or their representatives are encouraged to visit the home prior to making a decision. This is to ensure that all parties are happy that the individual’s assessed needs can be met at the home. Service users spoken with informed the inspector that they had made an informed choice about moving to the home. In addition to residential care, the home offers day care and respite care. This service can also be of benefit to a service user who may need or be considering residential care. Service users spoken with who had used this service prior to moving to the home informed the inspector that it made the transition of moving to residential care ‘easier’ and ‘much less stressful’. The home takes appropriate steps to ensure that the assessed needs of a service user can be met. The needs of existing service users are taken into account when considering a new service user. This is felt to be very positive. All prospective service users are fully assessed by senior staff at the home prior to a decision being made. Detailed documentation was seen in the care records for the two most recent service users. The home also obtains relevant assessments from other professionals where available. The home does accept emergency admissions but only where they are able to meet with the service user first and conduct a detailed assessment. This is felt to be very positive. The home has a contract with the local social services for 15 beds at the home. The same admission procedure is followed for these beds and the manager takes appropriate steps to ensure that admission is only offered to a service user where the home is sure that the assessed needs can be met and that there would be no negative impact on existing service users. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 11 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 standard(s) 7, 8, 9, 10 and 11 Service users benefit from a clear and consistent care planning process which promotes a person centred approach. Staff 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. EVIDENCE: The care records for the two most recent service users were examined at this inspection. Care needs were clearly identified and instructions for staff on how the assessed needs should be met were detailed and easy to follow. Copies of the home’s pre-admission assessments and assessments from other professionals were seen in the care records. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 12 Care records contained appropriate and up to date assessments relating to nutrition, reducing the risk of pressure sores and falls, and moving and handling needs. The inspector was able to see that care plans were being reviewed at least monthly. Records are maintained relating to significant daily events. Social history’s are obtained from the service user and/or representatives. 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. The inspector was advised that the home has an adequate supply of specialised equipment which included pressure relieving equipment, hoists and other equipment to meet the moving and handling needs of service users. The manager stated that the home does not experience any difficulties in accessing equipment for service users with an assessed need. Appropriate pressure relieving equipment was seen to be in place for one service user with an assessed need. Staff at the home ensure that service users privacy is maintained. All bedrooms are for single occupancy and 21 have en-suite facilities. Bedrooms are fitted with telephone sockets so to allow service users to have private phones if they so choose. The home also has a payphone which can be taken to individual rooms. Without exception, 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 they were ‘never rushed’ and 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. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 13 The home uses the Boots Monitored Dosage System (MDS) with pre-printed Medication Administration Records (MAR). A selection of MAR charts were seen and were found to be appropriately completed. Photographs are attached to aid identification. 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 staff on duty who have received appropriate training. The home’s arrangements dealing with death and dying are very good. The inspector was provided with examples of the support offered to service users and families following the death of a loved one. The manager ensures that, where families or friends are unable to remain with a service user during their final days, additional staff are provided so that the service user is not alone. Support is offered in accordance with the wishes of the service user and their religious beliefs. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 14 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 standard(s) 12, 13, 14 and 15 The home’s arrangements for ensuring that the expectations and preferences of service users is met is excellent. The standard and choice of food is excellent and service users benefit from a wholesome and varied menu. All standards were exceeded. EVIDENCE: The majority of the inspection was spent speaking to service users and observing staff interactions. 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, staff were heard to offer choices to service users and assistance was 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 D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 15 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. Service users informed the inspector that there was always something going on at the home and they could choose whether to take part or not. There is a weekly programme of activities, some organised by the homes activity worker and some provided by outside facilitators. On the morning of the inspection some service users were enjoying a word game in the dining room, some service users were socialising in other lounges, some people were reading or listening to the radio in their rooms and some people were undertaking their own craft activities. Service users informed the inspector that they enjoyed regular trips out. The home also has established excellent links with the local community and service users are able to enjoy regular outings to the towns shops, cafes and pubs. The manager should be commended for her efforts and enthusiasm in establishing and maintaining links with the local community. She ‘sits’ on several local steering groups and service users are kept well informed on local issues and events. The manager has ensured that all service users have access to their entitlement of free local council travel vouchers. The manager has also established links with the ‘Wivey Link’ and all service users are registered to receive reduced travel rates. The ‘Wivey Link’ provide service users with mini bus transport so that they can enjoy an increased number of trips out. Links with families and friends are encouraged. Annual meetings are held for families and representatives with minutes maintained. Visitors are made to feel welcome at the home. Service users benefit from wholesome meals and choices. Service users had nothing but praise about the food and choices available at the home. This was also reflected in the completed CSCI comment cards. Service users stated that the food was excellent at that snacks and drinks were always available. The home carries out nutritional assessments on each individual to ensure that any special needs are met. The preferences of service users are recorded. Service users confirmed that they choose where to have their meals, though the majority seemed to prefer the social atmosphere of the dining room. The dining room is spacious and comfortable. Tables were seen to be attractively laid. The atmosphere at lunch time was very relaxed. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 16 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 standard(s) 16, 17 and 18 The home has a satisfactory complaints procedure and service users know that their concerns will be listened to and acted upon. The home takes appropriate steps to reduce the risk of harm or abuse to service users. EVIDENCE: The home has produced a complaints procedure which is titled ‘Seeking your views’. Copies were seen to be displayed in various areas of the home. The home has not had any complaints since the last inspection. No concerns or complaints have been received by the CSCI. 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. Service users stated that they were encouraged to express their views and that they felt ‘listened to’. The home displays information for service users about independent advocates. The manager stated that nobody was using the services of an advocate at this time though assistance would be given to access this where required or requested. All service users are registered to vote. The home has a policy on the protection of service users from abuse. There is also a whistle blowing policy entitled the, ‘confidential reporting policy’. This Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 17 gives instructions on how to raise concerns within the company and to external agencies. The home follows robust recruitment procedures and all staff have undergone enhanced CRB checks and, where appropriate, POVAFirst checks. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 18 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 Pulsford Lodge provides service users with a safe, comfortable and homely environment, which has the specialist equipment to meet individuals needs. Service users are able to enjoy the privacy of their own bedroom or socialise in one of the many communal areas. EVIDENCE: Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 19 Pulsford Lodge is a purpose built home in Wiveliscombe. Accommodation is on two floors with a passenger lift. The home is well maintained with an ongoing programme of redecoration and plans to extend the building in the future. 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 and the en-suites in three bedrooms have been refurbished. 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. A large number of bedrooms are under 10 square metres but the home has ample compensatory communal space and Somerset Care is taking steps to address this. There are plans to increase the sizes of rooms and to install additional en-suite facilities. 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 hand rails 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. To ensure the safety of service users, radiators have been fitted with a guard and upstairs windows have been restricted in line with HSE guidelines. Bath hot water outlets are thermostatically controlled to ensure that they do not exceed HSE recommended limits. Hand washing facilities are appropriately sited to reduce the risk of the spread of infection. All areas seen at the inspection were clean and free from malodours. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 20 All service users spoken with and all completed CSCI comment cards indicated that service users enjoyed living at Pulsford Lodge and felt safe and well cared for. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 21 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Service users benefit from a staff team who have been very well trained. Staff morale is high and this has a positive outcome for service users. The home follows robust staff recruitment procedures which reduces 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. Nights are covered by 2 waking staff. The inspector was informed that this was sufficient to meet the assessed needs of individuals and that additional staff would be provided during the night or day, where there was an assessed need. Examples were given to support this. Where required, the home uses Somerset Care’s bank staff to cover any shortfalls. The manager stated that the same staff are used to ensure consistency for service users. Service users were very positive about the care they received and no concerns were raised regarding the numbers of staff on duty. Service users stated that their call bells were always answered promptly during the day and at night. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 22 Service users also stated that they ‘never felt rushed by staff’ and that staff ‘would do anything for you’. Other comments from service users included; ‘Staff are wonderful’, ‘They always have a laugh and joke with you’, ‘Nothing is too much trouble’, ‘they will do anything to help you’. Service users at the home benefit from a team of staff who have been appropriately trained. Somerset Care actively promote staff training. All staff undertake appropriate NVQ training. Information provided by the manager indicated that 73 of care staff have achieved a minimum of an NVQ2 in care. Staff spoken with were very positive about the training opportunities available to them and stated that the manager actively encouraged staff to express any training needs or preferences. 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. Newly appointed staff follow a detailed period of induction, which includes mandatory training. During this period the new employee works in addition to the care hours provided and is appointed a mentor who works closely with them. Following a satisfactory induction period, the new staff member then has a period working on shifts where they ‘shadow’ a more senior member of staff. The duration of this is determined on the needs and abilities of the staff member. Newly appointed staff do not work unsupervised until mandatory training is complete and that all are satisfied that the staff member is competent in all tasks and interventions. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 23 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 37 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: Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 24 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 4 years. She demonstrates an excellent knowledge of individual service users and staff members. There is an obvious commitment to upholding the rights of service users and this is filtered through to staff. Minutes of staff meetings seen give evidence that there is clear leadership in the home and support to staff to provide a high stand of care. Sonya has completed the Registered Managers Award (NVQ level 4 in care and management) The homes manager involves herself in the local community to ensure that the home is viewed as part of the community and facilities available locally meet the needs of the home. She should be commended for her enthusiasm and commitment to this. Staff and service users spoken with spoke very highly of Sonya and stated that she was very approachable. Sonya is very much a ‘hands on’ manager who ensures that she makes time to chat and socialise with service users as well as providing direct care to service users on occasions. Through discussion with Sonya, staff and service users, it was apparent that she has an excellent awareness and understanding of the assessed needs and preferences of service users living at the home. Regular meetings are held for service users, staff and representatives. Minutes are maintained. Service users, staff and visitors have named Sonya for the ‘Carer of the Year Award’ . Sonya has subsequently been selected as a finalist and will be soon attending a ceremony at a local Golf Club where the ‘winner’ will be announced. A final ceremony will be held in London. The inspector would like to wish Sonya all the best with this! The inspector was able to view a selection of completed quality questionnaires which had been issued to service users by the home. Results had been analysed by the manager and comments were very positive. The manager stated that the findings of the survey had been fed back to service users and their representatives and staff. Where appropriate or where requested, the home manages small amounts of ‘pocket monies’ for service users. Records pertaining to this were examined and were found to be well maintained. Receipts are maintained. Balances were not checked at this inspection but the manager stated that regular audits are carried out. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 25 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 is 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 home conducts weekly checks on the home’s fire detection systems and, as recommended at the last inspection, monthly checks on emergency lighting. Records were seen. Fire detection systems and fire fighting equipment are serviced by an outside contractor on an annual basis. This was last recorded as 12/08/05. The manager has completed a fire risk assessment dated 30/07/05. Staff training appeared up to date and the home has detailed information available to staff. ELECTRICAL SAFETY – The home’s portable appliances (PAT) are tested annually. This was last carried out 16/08/05. The manager advised that this was in the process of being completed. The home has an up to date electrical hardwiring certificate, which is due to be renewed. GAS SAFETY – The home’s last annual gas safety check was conducted on 05/05/05. 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. 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. The home carries out weekly checks to ensure the prevention of legionella. This involves running taps and soaking shower heads. EQUIPMENT SERVICING – All equipment relating to the transportation of service users is serviced by an outside company in accordance with LOLER regulations every 6 months. The home’s passenger lift was serviced on 03/08/05. Hoists were last serviced on 07/09/04. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 26 - To ensure the safety of service users, all upstairs windows are restricted, radiators covered and any free standing wardrobes are secured to the wall. - Environmental health last visited the home on 26/05/05. No issues were raised. - The home has a qualified first aider on every shift. Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 27 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 4 3 3 3 3 x 3 3 Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 28 no 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 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 Good Practice Recommendations Pulsford Lodge D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection 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 D53-D02 S16051 Pulsford Lodge V241809 060905 Stage 4.doc Version 1.40 Page 30 - 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!