Care Home: Pelsall Hall

Similar services:

• Maple Lodge
• Heathlands
• Aston Court Nursing Home
• Breme
• Ravenhurst
• Bank House
• Inspirations
• Ashcroft Hollow Nursing Home

Annual service review Name of Service: Pelsall Hall The quality rating for this care home is: The rating was made on: two star good service 2 5 0 3 2 0 0 9 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Wendy Grainger Date of this annual service review: 3 0 1 0 2 0 0 9 Annual Service Review Page 1 of 8 Information about the service Address of service: Paradise Lane Pelsall Walsall West Midlands WS3 4JW 01922693399 01922685525 pelsall@greensleeves.org.uk www.greensleeves.org.uk Greensleeves Homes Trust Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Conditions of registration: Category(ies) : dementia old age, not falling within any other category Conditions of registration: Number of places (if applicable): Under 65 Over 65 41 0 0 41 The maximum number of service users to be accommodated is 41. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender Either Whose primary care needs on admission to the home are within the following categories: Old Age not falling within any other category -Code OP maximum number of places 41. Dementia-Code DE maximum number of places 41 Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Pelsall Hall is a large detached property within in its own extensive grounds. The house has been converted to provide residential care for up to forty-one older people. The home has a large garden/dining room, a lounge area, Bistro, which is accessed by Annual Service Review Page 2 of 8 2 5 0 3 2 0 0 9 families and people using the service. A family room with internet access open to people using the service and families. The home has recently undergone major refurbishment and a large extension. This now provides people with better facilities, and a unit dedicated to the provision of care for people with dementia. Annual Service Review Page 3 of 8 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at the information we had received, or requested since the last key inspection. This included: The Annual Quality Assurance Assessment,(AQAA) that was completed and returned to us by the service. The completion of the AQAA is a legal requirement and it enables the service to undertake a self-assessment, which focuses on how well outcomes are being met for the people using the service. The AQAA also provides us with numerical information. What the service has told us about things that have happened in the service these are called notifications and are a legal requirement. We had contacted the service prior to commencing this Annual Service Review, to request that we could forward surveys to the people using the service and the staff. Surveys provide us with information of the outcomes for people using the service and any other comments they wish to make. At the time of this report we had not received the requested surveys in time to add the comments to the report. We contacted the service to clarify any changes that may be relevant since the receipt of the AQAA. It was agreed that the AQAA on file would be used as it remained current. What has this told us about the service? The completed AQAA was detailed, informative, it provided all the information we had requested. The service told us how they met the equality and diversity, which included: Through the recruitment process that has equal opportunity as a priority the service aims to actively recruit people from a wide range of backgrounds. The service enable people using the service to participate in the political process for people who remain interested in the election process. The AQAA told us that peoples rights are one of the fundamental principles of our philosophy of care, we actively encourage all of the people using the service to exercise their rights. Information for all the people using the service can be provided in a large print format or if necessary can be translated into Braille. The AQAA told us how they have improved in the previous months as a result of listening to the people using the service. The sensory garden has been completed. People using the service including those who have dementia can access the garden. Dining has been made a more sociable occasion with fresh flowers and table linen are provided. Wine is offered at meal times. People using the service are offered choice Annual Service Review Page 4 of 8 from the daily menus displayed on the tables. New staff have been employed recently. A new staff work rota has commenced with staff working four days on and four days off. No person would be admitted to the service without a full assessment of their needs based on the extensive pre-admission assessment. The AQAA told us that each person assessed would have a plan of the care they required, this would involve the person, representative and or family. The service has a Statement of Purpose which is reviewed on a regular basis. This document would provide prospective people and families with information about the service. Information in the AQAA told us all the care plans form a basis for the personal care, social, spiritual and risk assessments. The plan is seen by the service as a working document, which is reviewed ensuring it remains active and meeting the peoples needs. The medical needs of all the people using the service had been identified, arrangements were in place for the continued health needs provided by other professional agencies. People using the service were encouraged to maintain links with families, friends and the community. Information provided from the contact with the service told us that another activity coordinator had been employed providing people with the option to partake in activities five days a week. The AQAA told us that staff undertake an 2 day intensive course for the safe handling of medication. Staff are then observed until they are felt deemed to be able to dispense peoples medication. The service operates a bi-weekly medication audit, plus weekly staff drug audits. This practice ensures that standards are maintained to a high standard. We were told in the AQAA that as part of the discussions with the people using the service menus and activities enable the service to get feed back of the service provided. Within the last twelve months the AQAA tells us that they have increased the external activity programme including Tai chi sessions. The AQAA told us that the service has the complaints process within the required documents and displayed within the service. The service promotes a positive and transparent approach toward individuals comments both positive and negative. Records were maintained and concerns investigated. Policies procedures and staff training protect the people using the service from any form of abuse. All the staff were made aware of the procedure should they suspect Annual Service Review Page 5 of 8 anyabuse. The AQAA tells us that there had been two complaints made to the service they had been investigated and addressed to the satisfaction of all parties. One referral had been made to the safe guarding team, the issues were unsubstantiated. No complaints had been referred to us. The AQAA told us that the service had an on going refurbishment plan including: Two additional housekeeping staff have been employed this also includes a housekeeper/laundry person. A large 52 LCD,TV has been purchased for the large lounge A 42 TV has been purchased for the lounge used by people with dementia. The Bistro area has been established the service now has a PC with internet connection for the people to use. The hairdressing salon has been refurbished. The kitchen has been totally refurbished, the service had received the Clean premises Award from the environment health inspection. A new garden water feature had been completed. New laundry equipment had been purchased. A new call system had been installed the staff all carry DECT phones programmed to the system. The AQAA told us that systems were in place for the control of infection. Internal decoration is ongoing, peoples rooms are decorated when they are vacated. The AQAA told us that the service had a rigorous recruitment and selection process ensuring that references, Criminal Record Bureau (CRB), Protection of Vulnerable Adults (POVA) are obtained prior to employment. Information in the AQAA told us that staff training was current including the Metal Capacity Act and Deprivation of Liberties and other mandatory training. Information in the AQAA told us that the service had a low turn over in staff in the previous twelve months (4) From the contact with the service we were told that the staff had commenced an new concept of training (EDEN) where they are ensuring via training that people using the service are more involved including promoting their independence in daily life skills. The manager has had a number of years in the caring profession. She was registered for the service with us in March 2008. Over time the AQAA tells us she had developed new systems of communication, record keeping, assessments and care plans. Annual Service Review Page 6 of 8 What are we going to do as a result of this annual service review? We are not going to change our inspection plan, and will do a key inspection by the 23rd March 2011. However we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 7 of 8 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a copy of the findings in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Annual Service Review Page 8 of 8 - 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!