Care Home: Pelham Grove Residential Home

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What the care home does well People who are thinking about moving in are given up to date information about the home and their needs are properly assessed so that they can be sure that it is the right place for them to live. Available at the home was an up to date care plan for each of the residents, which clearly set out how staff need to meet their health, personal, and social care needs. Staff showed good knowledge and understanding of the needs of the residents, during the inspection visit they were observed talking to residents in a polite manner and treating them with respect. Residents spoken with said that staff are always polite and treat them well they made the following comments to support this: "Oh, yes the staff always treat me well" "All the staff are always kind and polite" "Staff are very caring" "Staff always knock on my bedroom door before coming in" "The staff never rush me, they are patient and gentle". The home had in place appropriate procedures for responding to concerns complaints and for ensuring that residents are safe from abuse, harm or neglect. The commission have not received any complaints about the home since the last inspection. Everybody spoken with during the inspection said that they had been given information about how to make a complaint if they needed to. Residents were confident that their complaints would be listened to and dealt with in the correct way. The home was comfortable, well maintained and free from hazards making it a pleasant and safe place for people to live. More than half of the staff team have achieved or are working towards a National Vocational Qualification in Care level 2 or above and they have all completed or are planning to complete training linked to the aims and objectives of the home and the needs of the residents. The home is well managed to the benefit of the residents and staff. What has improved since the last inspection? The system for managing residents savings has changed ensuring that they are protected and that they receive the interest accrued. All the work required has been carried out to ensure the continued safety of the home`s electric wiring circuits. What the care home could do better: All the standards which were assessed during this inspection either met or exceeded the National Minimum Standards for this type of service. CARE HOMES FOR OLDER PEOPLE Pelham Grove Residential Home Pelham Grove off Lark Lane Liverpool Merseyside L17 8XD Lead Inspector Janet Marshall Key Unannounced Inspection 09:30 5 December 2008 th 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 Pelham Grove Residential Home DS0000025190.V367168.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. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pelham Grove Residential Home Address Pelham Grove off Lark Lane Liverpool Merseyside L17 8XD 0151 727 0758 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) www.southerncrosshealthcare.co.uk Southern Cross Home Properties Limited Irene Hughes Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 35 Personal Care Beds. Three named persons under 65 years old may be accommodated, within the overall total of 35. The Manager will obtain an NVQ Level 4 qualification in management and care, or the equivalent. 12th December 2006 Date of last inspection Brief Description of the Service: Pelham Grove is a purpose built care home in the Sefton Park area of Liverpool. It is situated off Lark Lane and is close to local amenities and public transport. The home provides personal care for 35 Older People. Accommodation is provided in single bedrooms on two floors. Access to rooms on the second floor is by the lift or the stairs. Some of the bedroom are large and can be shared by a married couple or on request. In addition the home has aids to promote the safety of the residents such as grab rails, assisted baths, hoists, and a staff call system. The home has a dining room and lounge on the ground floor and an additional sitting room on the first floor, which is also used as an activity room. An Information pack about the home is available at the entrance and includes a copy of the most recent CSCI inspection report. It cost between £307.50 to £433.00 each week to live at the home. Pelham Grove Residential Home DS0000025190.V367168.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 2 star. This means the people who use this service experience good outcomes. This was a key inspection. The Commission considers 22 standards for Care Homes for Older People as Key Standards, which have to be inspected during a Key Inspection. All key standards for this type of service are highlighted in bold in the relevant sections of this report. The report has been put together using information gathered from a number of sources including information that we have received about the service since the last inspection which took place in December 2006 and details provided in the Annual Quality Assurance Assessment (AQAA). The AQAA which is in two parts, a self-assessment and dataset provides us with important information about the service which helps us decide how good it is. It was sent out to the service, completed in good detail by the manager and returned us before the site visit took place. The inspection also involved an unannounced visit to the home (site visit). This was carried out with the help of the deputy manager (who is currently the acting manager at the home in the absence of the registered manager) and care staff that were on duty at the time. Records that were examined, staff comments and observations made during the visit have also been used as evidence for the report. The Commission sent out surveys to people who use the service and staff before the site visit took place, however none of them were returned at the time of writing this report. A number of residents were spoken with during the site visit and their views and opinions about the service are reflected within the report. A number of residents were case tracked. This process involved talking to them, looking at the environment and a selection of their records such as assessments, care plans and daily notes to get an idea about their experiences and to find out if they are receiving the care and support that they need and which they have agreed. What the service does well: Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 6 People who are thinking about moving in are given up to date information about the home and their needs are properly assessed so that they can be sure that it is the right place for them to live. Available at the home was an up to date care plan for each of the residents, which clearly set out how staff need to meet their health, personal, and social care needs. Staff showed good knowledge and understanding of the needs of the residents, during the inspection visit they were observed talking to residents in a polite manner and treating them with respect. Residents spoken with said that staff are always polite and treat them well they made the following comments to support this: Oh, yes the staff always treat me well” “All the staff are always kind and polite” “Staff are very caring” “Staff always knock on my bedroom door before coming in” “The staff never rush me, they are patient and gentle”. The home had in place appropriate procedures for responding to concerns complaints and for ensuring that residents are safe from abuse, harm or neglect. The commission have not received any complaints about the home since the last inspection. Everybody spoken with during the inspection said that they had been given information about how to make a complaint if they needed to. Residents were confident that their complaints would be listened to and dealt with in the correct way. The home was comfortable, well maintained and free from hazards making it a pleasant and safe place for people to live. More than half of the staff team have achieved or are working towards a National Vocational Qualification in Care level 2 or above and they have all completed or are planning to complete training linked to the aims and objectives of the home and the needs of the residents. The home is well managed to the benefit of the residents and staff. What has improved since the last inspection? What they could do better: Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 7 All the standards which were assessed during this inspection either met or exceeded the National Minimum Standards for this type of service. 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. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 does not apply as the service does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are given information about the home and their needs are properly assessed before a decision is made about them moving there. EVIDENCE: The Homes Statement of Purpose and Service User Guide have been updated since the last inspection. Both documents, which were examined, included all the information which is required by regulation. The AQQA told us that all the information included in the homes brochures are available on DVD and in large print should anyone require this format. Details provided in the AQAA and discussion with residents and the acting manager showed that the documents are given to people who are thinking about moving into the home. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 10 A newly admitted resident said, “Yes I was given a lot of information about the home and I visited with my family before I decided to live here”. The AQAA showed that a number of residents have been admitted to the home in the last twelve months. The acting manager confirmed that pre-admission assessments were carried out for all newly admitted residents. Pre-admission assessments were looked at for five residents that have moved into the home in the last twelve months. All assessments which were carried out by a member of the management team were detailed and covered, sight, hearing, social contacts, medical history, mobility, personal care and safety. Each of the files examined also included an assessment checklist. The acting manager confirmed that pre-admission assessments for all new residents are only carried out by qualified staff including himself. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents personal and healthcare is well monitored and supported ensuring they stay well. EVIDENCE: Each of the residents had an individual care plan which was kept securely at the home. The acting manager explained that he is in the process of re writing all residents care plans so that they are written in a more person centred way. A selection of care plans were looked at during the inspection visit as part of the case tracking process. Care plans clearly set out the persons care need requirements and the action that staff need to take to ensure they are met. There was evidence to show that care plans are regularly reviewed with the involvement of residents and/or their representative. Staff spoken with showed a good understanding of care plans and how they use them to ensure that resident’s needs are identified and met. Staff said care plans are important because: Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 12 “They give us important information about the resident and how best to care for them”. “A care plan helps us find out about the resident, what their care needs are and about their likes and dislikes”. “Care plans are important and need to be kept up to date so that we have all the right information about a resident”. Records of medical appointments were kept in good detail and showed that residents have regular access to specialist medical, nursing, dental, chiropody and GP services. Residents spoken with confirmed that they could see their doctor when they choose. The acting manager confirmed the arrangements that are in place at the home to enable residents to access other specialist services such as speech therapists and dieticians. Records completed by visiting health care professionals such as district nurses and GPs were also in place and well kept. The home has policies and procedures for monitoring and the treatment of pressure wounds. These showed that the relevant professionals are consulted and involved in treating wounds. Records for monitoring and the care of pressure wounds were well kept. The AQAA provided details of a number of other policies and procedures, which relate to the health care of residents including control, administration, recording, safe keeping, handling and disposal of medication. Medication was stored safely at the home and records, which were looked at, were well maintained. The lunch time medication round was observed, medication was administered and recorded correctly. The acting manager confirmed that a local pharmacist prepares and delivers prescribed medication to the home. Discussion with staff and examination of records showed that medication is handled only by staff who have received training in this subject. At intervals throughout the inspection visit staff were observed respecting resident’s dignity and their right to privacy they did this by knocking on doors before entering rooms, assisting residents with personal care in private, talking to them in a polite manner and treating them with respect. Residents spoken with said that staff always treat them well and respect their privacy and dignity. They made the following comments to support this: Oh, yes the staff always treat me well” “All the staff are always kind and polite” “Staff are very caring” “Staff always knock on my bedroom door before coming in” “The staff never rush me, they are patient and gentle”. Comments made by staff, which supported their understanding of, care values such as privacy, dignity and respect included: “I always close doors when helping residents with personal care” Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 13 “I knock on doors before entering a room, talk to the resident to put them at ease. “I always give residents choices and encourage them to do as much as they can for themselves. It is important to encourage residents to be independent. “I talk to residents when helping them”. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 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. 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. The home has on offer a wide range of recreational, leisure and educational activities which matches resident’s preferences and needs. EVIDENCE: Pre- admission assessments and care plans detailed residents social preferences and lifestyles. Information about their likes and dislikes, past lives, social interests and hobbies were well recorded to enable staff to appropriately support these needs. The AQAA showed that resident’s routines and daily lives are varied and flexible to suit the individual needs of the person. An activity co-ordinator is employed at the home 5 days a week. Records viewed during the inspection visit showed she has compiled a social history for each of the residents which includes information about their hobbies, interests and favourite pastimes. This information enables her to match activities and events to residents individual preferences and put together a programme which includes something for all. The activity co-ordinator also keeps a daily Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 15 activity record for each of the residents enabling her to monitor their involvement and development. The activity co-ordinator facilitates a wide range of activities for residents both in and outside the home. A monthly activities planner was on display at the home, it provided residents with clear information about a planned activity or service. The planner included a variety of suitable activities and services for residents to choose from both in and outside the home including pamper days (hairdressing and manicures), arts and crafts, aromatherapy, film shows, and bingo, singing and dancing. Residents and staff spoken with said there is an excellent range of activities at the home. The activity co-ordinator reported that church services and Holy Communion are regularly held at the home for those residents who choose to take part. Information detailing religious services was also on display at the home. Also displayed around the home were photographs showing residents and staff clearly enjoying themselves at parties and theme nights organised at the home. Residents art work was also displayed around the home. During the inspection visit residents said: “There is so much to do here every day”. “The choice of activities was one of the reasons I chose to live here”. “I really enjoy the activities”. “We go out quite a lot” “When I came to live here I was very surprised at the amount of things that go on”. A hairdresser who was visiting the home at the time of the inspection confirmed that she visits each week to provide a service to those residents who have requested it. A visitor’s book, which was seen at the home, showed that residents receive regular visits from friends and family members. During the inspection visit residents were seen making choices for themselves, others were seen being encouraged by staff to make choices. Residents spoken with confirmed that they choose what clothes they were each day and decide what time they get up and go to bed. A member of staff said, “I encourage residents to be independent”. Assessments and care plans detailed daily tasks and activities, which residents can and should be encouraged to carry out independently. The dining room which is on the ground floor close to the main entrance was clean, bright and decorated and furnished to a very good standard. There were a number of small dining tables, which were attractively set with table cloths, napkins and cutlery, there was also a small display of flowers in a vase in the centre of each table. A menu for the day was displayed on each table. Residents spoken with confirmed that there is a menu on display each day. They also said each morning staff remind them of what is on the menu for that day and ask them what they would like. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 16 Lunchtime was spent with residents and the food was sampled. Staff served residents individually with their choice of meals. Meals were nicely presented and generous in portions. Staff assisted residents in a sensitive and unrushed way. Residents were given time to eat their meal at a pace that suited them. Hot and cold drinks were served and residents were offered seconds. Food stores were well stocked with a variety of fresh, frozen, tinned and dried foods. The kitchen was equipped with appliances such as a microwave, fridge and freezer and had a good supply of cooking utensils. The menus, which were viewed, included a variety of well-balanced and nutritious meals. Residents spoken with were very satisfied with the meals at the home. They made the following comments to support this: “The food is excellent” “We are always given a choice of food” “It couldn’t be better” Although residents are encouraged to eat their meals in the dining room they can choose to eat in their own rooms if they wish. Residents were offered drinks and snacks at intervals throughout the day. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 17 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are fully protected by procedures and processes which are in place at the home and they are confident about complaining if they need to. EVIDENCE: The commission have not received any complaints about the home since the last inspection. The AQAA showed no complaints have been received at the home in the last year. Residents spoken with during the inspection visit said they know who to speak to if they were unhappy and that they know how to make a complaint, they also said they were confident that their complaint would be dealt with in the right way. Comments made by residents during the inspection included: “I have nothing to complain about, if I did I would tell someone”. “Yes I would most definitley complain, I have been given information about how to complain ”. “I wouldn’t hesitate and yes I know who to speak to, the person in charge”. Available at the home were a number of policies and procedures, which aim to ensure the protection of both residents and staff. They included, complaints whistle blowing, and protection of vulnerable adults procedures. The AQAA showed that all these policies and procedures have been reviewed and updated Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 18 in the last two years. The AQQA told us that available at the home are easily read versions of complaints and protection procedures for those residents who request or need them. Staff spoken with were familiar with all of the procedures and said they were confident about using them if they needed to. The AQAA told us that all staff have completed Protection of Vulnerable Adults training. This was also confirmed by a number of staff that were spoken with during the inspection visit. Those staff were confident about what they would do if they thought a resident was being abused and they correctly described the procedures they would to follow. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 19 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and well maintained environment. EVIDENCE: Pelham Grove is a purpose built Residential Care Home located in a popular residential area close to Sefton Park, Liverpool. There are good transport links and community services and facilities including churches, cafes and community health centres that are within close distance of the home. At the front of the home is a large drive way which is big enough to provide off road parking for a number of vehicles. Mature trees, bushes and shrubs surround the front and sides of the building. The home is made up of two floors with resident’s bedrooms situated on both. The kitchen and laundry are located on the ground floor, these areas are not accessed by residents for safety reasons. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 20 Specialist equipment in place to assist residents with mobility include ramps, bath-lifts in the main bathrooms and handrails located around the home. The home also had a passenger lift which operates from the ground floor up to the first. The AQAA detailed a number of improvements carried out at the home since the last inspection. The improvements which were looked at during a tour of the home included the following: • A number of resident’s bedrooms have been fitted with new carpets. • The carpet in the foyer has been replaced. • A giant cinema screen and projector have been purchased. The AQAA told us that an ongoing maintenance programme is in place detailing the plans for further improvements including the redecoration of the kitchen, lounges, hairdressing room and the replacement of chairs in the foyer. Throughout the inspection visit there was a warm and friendly atmosphere at the home. All parts of the home were clean, pleasant and hygienic and there were no hazards identified at the time of the inspection. Residents spoken with said that their rooms and other parts of the home are always clean and tidy. They made the following comments: “The home is always very clean” “My room is always kept clean, although I like do a bit for myself, I make my own bed and clean my bathroom” “There are never any nasty smells here” The laundry, which is located in the basement area, was equipped with sufficient washing and drying machines and ironing facilities. The laundry was clean and well organised. Detailed in AQAA and available at the home were a number of policies and procedures, which aim to ensure a clean and safe environment, they include infection control and disposal of soiled waste. Staff were seen appropriately using protective gloves and aprons. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 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 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. Recruitment and training of staff ensure that residents are supported by the right people. EVIDENCE: The staffing rota, which was examined as part of the inspection showed that there are a sufficient staff on duty to meet the needs of the residents. Discussion with the acting manager and information provided in the AQAA showed that the staff turn over and use of agency staff has been low since the last inspection. Three members of staff were interviewed during the inspection. General discussion also took place with a number of other staff at intervals throughout the visit. They said that there is always enough staff on duty to meet the needs of the residents. Staff interviewed showed a good understanding of their roles and responsibilities, were very knowledgeable about the needs of the residents and showed a real commitment to ensuring that they are well cared for and have a good quality of life. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 22 Residents spoken with during the inspection visit made many positive comments about the staff, comments included: “The staff are great”. “The staff are well trained”. “The staff are really nice and are good at their jobs”. “The staff are excellent”. “The staff are fantastic”. “The staff listen and are very understanding”. An equal opportunities policy and procedure was available at the home. The AQAA showed that staff employed at the home are people of various ages, gender and of different backgrounds. The AQAA told us that there are strict recruitment and selection procedures operated at the home to ensure the full protection of residents. This was also evidenced upon examination of records for three staff that have been recruited since the last inspection. Each member of staff has a personnel and a training file which were well organised and easy to access. An administration checklist was at the front of each staff file showing details of checks carried out. The records showed the required checks were carried out before the people were allowed to start work at the home. Staff receive a good level of training which ensures that residents are cared for and supported by an appropriately qualified staff team. The AQAA told us that all new staff take part in induction training when they start work at the home, records viewed also showed this. The AQAA also told us staff have received a good amount of training relevant to their jobs. Each member of staff had a training and development plan which is used to assess and identify their individual training needs. A training matrix showing future training planned was available at the home. The matrix included the following topics: moving and handling, pressure care, challenging behaviour, dementia awareness, medication and first aid. Staff spoken with said that they have completed a lot of training since the last inspection and gave the following examples, fire safety health and safety, POVA, medication awareness and first aid. The AQAA and staff training records held at the home showed that more than half the staff team have achieved a National Vocational Qualification (NVQ) in care level 2 or above. NVQ training was also included in training planned for the future. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 ,35 & 38 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The home is well managed to the benefit of the residents and staff. EVIDENCE: The registered manager of the home was on sick leave at the time of the inspection visit. The deputy manager had been appointed to act as the temporary manager in her absence. The Commission has been notified in writing of this arrangement. The deputy manager has worked at the home for a five years and has a number of qualifications relevant to his work. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 24 There was evidence from this inspection that processes and records for staff development and supervision, recruitment and selection of staff and systems for monitoring the quality of the service are all in place and being managed efficiently in the interests of the residents. Residents and staff spoken with during the inspection were complimentary of the manager/s and the way the home is run, the following comments made during the inspection supported this: “The home is managed very well”. “You can talk to any one of them”. “I Know I can talk to the manager”. “The manager is very good to the residents and always has time for them”. “the manager/s are approachable and very supportive”. “I get on well with the manager/s”. Discussion with the acting manager and records, which were examined, showed that the home has in place a number of quality monitoring systems, which aim to ensure that the home is run in the best interests of the residents. Satisfaction questionnaires are given out to residents and their representatives as a way of seeking their views about the home. The results taken from them are used to plan and make improvements for the future. Southern Cross who own Pelham Grove, act as appointee for a number of residents. The homes administrator keeps a record of all transactions made by or on behalf of those residents. It was noted at the last inspection that savings managed on behalf of individual residents were kept in a separate Southern Cross account and the interest earned was being used to support activities in the home. A requirement was given as part of the last inspection report for this system to be changed because it was inappropriate for the company to use money that rightly belonged to individual residents to support activities in the home. The company has changed this system in the interest of the residents. A residents savings account has been opened by Southern Cross in the name of each resident who has money deposited. Interest earned from the account is allocated to the residents according to the level of their investments and none of it is used to supplement the company’s responsibility to provide activities in the home. Records and money for a number of residents were looked at and checked they were in good order and well kept. The health safety and welfare of residents are well protected this was supported by a set of policies and procedures, which were detailed in the AQAA and available at the home. All the homes policies and procedures have been reviewed and updated in the last two years. A requirement was given following the last inspection to ensure that work is carried out on the homes electrical wiring circuits, this was because the last Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 25 inspection evidenced that it had taken several months for essential work to be carried out on the circuits putting residents health and safety at risk. Records seen during this inspection showed that the required work has been carried out and certificates were in place confirming the saftey of the homes electrical wiring circuits. Information provided in the AQAA and examination of a selection of health and safety records showed that other required health and safety checks have been carried out on the environment at the required intervals, for example fire system checks, gas and electrical appliances checks and environmental risk assessments. Staff and residents spoken with confirmed that they hear the fire alarm system regularly being tested. Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 26 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 X 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 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 3 X 3 X 3 X X 3 Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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 Pelham Grove Residential Home DS0000025190.V367168.R01.S.doc Version 5.2 Page 29 - 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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