CARE HOMES FOR OLDER PEOPLE
Peacehaven 101 Roe Lane/1a Derwent Avenue Southport Merseyside PR9 7PD Lead Inspector
Mr Paul Kenyon Unannounced Inspection 14th February 2006 12:00 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 Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Peacehaven Address 101 Roe Lane/1a Derwent Avenue Southport Merseyside PR9 7PD 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) 01704 227030 Peacehaven House Mrs Lynne Nuttall Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52) of places Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 52 Old Persons The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Date of last inspection Brief Description of the Service: Peacehaven is an older property that has been converted into a care home providing personal care for 52 older persons. It is pleasantly situated in a leafy part of Southport close to public transport and within easy reach of the amenities that serve the area. Peacehaven House Trust (registered charity) owns the home and Mrs Lynne Nuttall manages it. Peacehaven currently has 52 single bedrooms placed on two floors. A further three bedrooms are being built within an extension to the property and this is ongoing. The use of these rooms will be subject to registration with the Commission For Social Care Inspection and it is hoped that these will be ready for use in March 2006. A passenger lift provides access to upper floors. The home offers intermediate care to five persons. All the bedrooms have pleasant views of the gardens. Communal space currently provides 3 sitting rooms, 2 dining rooms and a conservatory. There is also a smaller lounge that acts as a designated smoking area. The home has currently two ramps in place, which enable service users to access the grounds from the front and side doors, with garden furniture suitable for use by service users and their visitors. The home has a variety of hoists and suitably adapted equipment to assist with the varying needs of service users. There is also a call alarm system throughout the home including all bedrooms. Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection to be held this inspection year (April 2005 to March 2006) and took place during the early afternoon. The visit was unannounced and lasted three and a half hours. The visit used the National Minimum Standards for Older People to measure how well residents were being looked after and included a tour of the premises, examination of a number of records as well as detailed discussions with three residents who had some to live at Peacehaven since the last inspection in 2005. What the service does well:
The service is good at ensuring that it respects the privacy of residents and that they consider that their privacy is respected and that they are treated in a dignified and respectful manner. The service is good at ensuring that residents can maintain contact with their families and friends and that such visitors can be received in private. The service is good at enabling residents to have information about local advocacy services, feel that they can maintain their independence in daily life and that they are enabled to bring in personal possessions into the home. The service is good in the main at providing a good quality of food with a varied menu and choice of preferred meals. The service provides an environment that is comfortable, well decorated and is subject to a refurbishment plan. The service also provides a clean and hygienic environment for residents, which is free completely of offensive odour. The service is good at providing consistent staffing levels with a mix of care and ancillary staff. The service demonstrates a commitment to ensuring that staff are enabled to undertake qualifications linked to National Vocational Qualifications (NVQ) at Level 2 and 3. The service is good at identifying training for staff and monitoring training courses that have been attended. The service is well managed with a Registered Manager in place who is experienced and qualified and is supported by a management structure which includes individuals who are in turn experienced. Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 6 The service is very good at measuring the quality of care that it provides through the involvement of external and independent groups, representatives of the committee that run the home, internal audits by the Manager, residents’ groups and in facilitating the inspection process by the Commission For Social Care Inspection. This standard is exceeded. The service is good at keeping secure and accounting for any monies given for safekeeping by residents. Three residents held detailed discussions with the Inspector. All residents had come to live at Peacehaven since the last inspection in 2005. Comments made by residents included: ‘I can have privacy anytime I want’ ‘I can do what I want to do’ ‘There is plenty of things to do’ ‘Food is absolutely gorgeous’ ‘I am quite happy’ ‘Staff are absolutely excellent. I have never met such nice people’ ‘Staff will do anything for you’ ‘I am very happy here’ ‘It is super here’ ‘They are kind and helpful’ ‘I have my privacy’ ‘I have been able to bring my own furniture in’ ‘Food is absolutely marvellous’ ‘I can get around myself and they let me do that’ ‘The building is clean’ ‘It is super here’ What has improved since the last inspection?
The service now gets information about the needs of all residents before they come into the service so that these needs can best be met. The service now has a certificate that confirms the safety of the gas supply to the building and certificates are now available to confirm that portable hoists used to transfer residents have been tested and serviced to the required frequency. These were all requirements at the last inspection and are now all addressed. Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 7 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. Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 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 Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 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 the following standard(s): 3. Standard 6 was measured at the last inspection and was met. Residents benefit from having their needs assessed by the home prior to them living at Peacehaven. EVIDENCE: A requirement at the last inspection highlighted the fact that assessments for residents had not been obtained prior to them living at Peacehaven in all cases. A number of assessments relating to residents who had come to live in the home since the last inspection were examined. It was noted that in all those sampled, assessments were available and indicated that their needs could be met by the staff team. This requirement has now been addressed. Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10.Standards 7, 8 and 9 were measured at the last inspection and were met Residents consider that the staff and environment at Peacehaven uphold their privacy and dignity. EVIDENCE: All residents who spoke to the Inspector confirmed that they have their privacy respected: ‘I can be on my own or go to the lounge’ ‘I have my key to the door’ I was offered a key but I don’t use it’ Care plans noted that the preferred names of residents had been recorded. Clothing in the laundry area was noted to be discreetly marked to minimise loss of items or people wearing other people’s clothing. Keys are available to all residents for their bedrooms with some using them and others preferring not to. Locks are in place on all toilet and bathroom doors. The induction form for new staff includes reference to the need for staff to promote privacy. A number of residents have been able to have telephones installed in their
Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 11 rooms. All residents who spoke with the Inspector considered that staff were respectful to them ‘Staff are so nice’ I have never met such a caring team of people’ There are no shared rooms at Peacehaven. A number of bedroom doors have labels. These indicate whether a resident wishes to be disturbed during checks by night staff or whether they would prefer to stay longer in bed during the morning. Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14 and 15. Standard 12 was measured at the last inspection and was met. Residents benefit from a service that enables them to keep in touch with family and friends. Residents benefit from a service that enables them to be as independent as possible. In the main the nutritional needs of residents are taken into account by the catering arrangements in place. EVIDENCE: All residents confirmed that they receive visitors: ‘My family and friends visit’ ‘I can always see them in private’ ‘It is nice to be able to offer them a drink and biscuits just like you would do at home’ ‘Sometimes I get too many visitors!’ A visitor’s book is located in the reception areas of the home and this confirmed that amount of community contact. Other information relating to activities noted that a number of external groups are involved in assisting with activities. These included in house entertainers and representatives from local churches.
Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 13 Residents confirmed that they are able to be as independent as possible ‘I can do what I want’ ‘I could go out at anytime and I know lots of people who do’ Some individuals are either completely independent with their finances or rely on their families rather than the Manager to deal with financial affairs. The Manager does have a role but this is limited to keeping monies for safekeeping following the wishes of residents. Information about a local advocacy service is available to residents and this service has been utilised in the past. All residents who spoke to the Inspector were asked about their personal possessions. All were able to point to items within their rooms that belonged to them. In one case, nearly all the furniture belonged to the individual. An inventory of property is completed on admission. This indicates which property in a room belongs to the resident and which belongs to Peacehaven. One form had not been completed and this is raised as a good practice recommendation in this report. The provision of food was looked at in depth at this inspection. Comments on the food by residents have been outlined earlier in this report. On admission, a nutritional assessment is completed. This is then included within care plan reviews. In one case, an assessment had not been fully completed. This is raised as a requirement in this report. Once the assessment is completed, a kitchen notification form is completed and this provided catering staff with information about any dietary needs or other general preferences. The Cook was able to confirm the information that he had received about dietary needs and this is available for all catering staff within the kitchen area. Menus are available and are on prominent display. Residents confirmed that choice and alternatives are available and that any choices are determined in advance. One resident commented ‘We are never rushed when eating’. The kitchen is a well-equipped and well-organised area. The home has recently had a Food Hygiene inspection and the report indicated that no areas of concern had been highlighted. The Cook explained that he was striving to incorporate new food hygiene guidance into the systems within the kitchen. Refrigerators and freezers were well stocked and records indicated that the ordering of foods from suppliers was organised. A dining room is available. This is a pleasant area. One resident confirmed that ‘you can have your meal in your room if you are not feeling too good’. Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards in this section were measured during this inspection. Standards 16 and 18 were examined at the last inspection and were met. EVIDENCE: Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Residents benefit from a well-maintained environment that is clean and hygienic. EVIDENCE: A tour of the premises was made in all communal areas, some bedrooms and other areas of the home. In all areas, the decoration was well maintained and a home like environment had been created throughout. Redecoration had been completed in the hallway and landing area of one part of the building since the last inspection and this creates an attractive and bright reception area. A refurbishment plan has been devised for the next twelve months. This highlights work that is needed both internally and externally in the forthcoming months. The Inspector noted some minor wear and tear to the decoration during the tour of the building as well as the need to replace some carpets at some point yet these had all been identified within the plan. The home has large grounds available to residents and work has been included in the plan to
Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 16 ensure that the gardens are maintained during the forthcoming spring. Access to these grounds is possible at various points. A laundry is situated separately from all food preparation areas. This is a wellorganised area with impermeable flooring for ease of cleaning and contains a number of washing and drying appliances. Throughout the tour of the building, no offensive odours were detected and the building throughout remained clean and hygienic. A number of domestic staff are employed throughout the day to ensure that standards of hygiene are maintained. Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Residents benefit from staffing levels and a mix of staff roles that meet their needs. Residents benefit from a qualified and well trained staff team. EVIDENCE: A staff rota is available recording the designation of all staff on duty. Included in this rota are ancillary staff. The service aims to have six care staff on duty during the day with one member of staff identified as the person in charge of the shift. The Manager considers that the care plan review process has aided a view to be formed that dependency levels in the home are medium to low at present and that staffing levels at the moment meet the needs of residents. Ancillary staff are employed to maintain standards of hygiene in the home as well as kitchen staff employed to provide catering. These posts ensure that care staff can concentrate on their role. Records confirmed that many staff have attained NVQ Level 2 and in some cases have moved on to Level 3. Certificates held were able to confirm this. The process of attaining NVQ qualifications continues for the remainder of the staff. Records are also available to confirm that staff undertake a training programme. This includes mandatory training as well as other training such as diabetes awareness and abuse awareness that is relevant to the needs of residents. Certificates of training were available and examined to confirm this. An induction process is in place and this contains reference to the terms of
Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 18 conditions of employment as well as an emphasis on the values needed to meet resident need. Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33 and 35. Part of standard 38 was measured to ensure that requirements raised at the last inspection had been addressed. Residents benefit from a well-managed service, which assesses the quality of the service provided to them. The level of quality assurance leads to a conclusion that this standard has been exceeded. Health and safety systems now protect residents and staff. EVIDENCE: The Manager is an experienced individual who is qualified to fulfil her role. She is in turn aided by a management team that have been delegated with a number of care related tasks such as training. The Manager is only responsible for this service. The Manger confirmed that she has undertaken recent training in abuse awareness as well as medication training. The Manger seeks to update herself with training but also in areas of regulation Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 20 Quality assurance systems take many forms. The Inspector considers that this standard has been exceeded on this occasion. Firstly, the Manager conducts her own audit and issues questionnaires to residents and families inviting them to comment on their experiences of the home. The results of this process have been put on prominent display for residents to consider. The home facilitates a residents’ committee. These individuals hold monthly meetings and provide minutes. The minutes for the last two meetings were examined. These indicated that residents were happy with the service provided although any small issues that are nevertheless important to residents are dealt with. The home complies with legislation with members of the Committee that run the home conducting monthly, unannounced visits. This process involves interviews with residents, staff, a tour of the building and the examination of records. A report is then made available and reports form recent months were examined during this visit. The home receives an annual and independent assessment from an external agency. Again this provides part of the quality assurance process. The management and staff team remained co-operative throughout the inspection and were able to facilitate discussions between the Inspector and residents. All requirements from the previous visit have been responded to promptly. Care plans provided evidence that some residents enabled their families to deal with finances relating to Power of Attorney and appointeeships. The home has no role in this yet provides a system for the safekeeping of residents’ monies. All monies are securely held and records are available. No monies are pooled but are individually stored. Records are audited frequently with one being held in November 2005 and another in January 2006. Receipts are obtained in all cases. A requirement at the last inspection highlighted the need for a certificate to be produced confirming the safety of the gas supply to the building. A certificate was produced during the visit to confirm this. In addition, a further requirement had been raised to confirm that portable hoists were serviced on a six monthly basis. Again certificates were produced to confirm that this had been done. All requirements have now been addressed. Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 21 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 22 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. 1. Standard OP15 Regulation 12 Requirement The nutritional assessment as identified at the inspection must be completed Timescale for action 28/02/06 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 OP14 Good Practice Recommendations The personal possessions inventory as identified at the inspection should be completed. Peacehaven DS0000005352.V282211.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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