Inspection on 16/11/06 for Peacehaven

This inspection was carried out on 16th November 2006.

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

Peacehaven 10/11/08

Peacehaven 08/02/06

Peacehaven 31/10/05

Peacehaven 11/01/05

Peacehaven 22/11/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Peacehaven 12 Kenilworth Road Leamington Spa Warwickshire CV32 5TL Lead Inspector Michelle O’Brien Key Unannounced Inspection 16th November 2006 09:10 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 DS0000004229.V308670.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. Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Peacehaven Address 12 Kenilworth Road Leamington Spa Warwickshire CV32 5TL 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) 01926 429968 01926 424894 peacehaven@cch-uk.com Christadelphian Care Homes Mrs Linda Prain Care Home 21 Category(ies) of Dementia (14), Old age, not falling within any registration, with number other category (21) of places Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The seven bedrooms in the annexe on the first floor of the home are identified for only older people without a diagnosis of dementia. 8th February 2006 Date of last inspection Brief Description of the Service: Peacehaven is a large, period house, which is situated off the main road leading into Leamington Spa town centre and its amenities. The Bethany Guild owns the home and the Christadelphian Hall is attached to the home. Peacehaven is registered to provide care to 24 elderly service users. Service user accommodation is provided over two floors with access via passenger lift or stairs. The majority of service user accommodation has en-suite provision. The currently weekly charge is £345 - £465 per week. Chiropody is included but there are additional charges for hairdressing. The home’s ‘Welfare Fund’ provides for outings and some other activities at no cost to service users. Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report uses information and evidence gathered during a key inspection process which involves a fieldwork visit to the home and looking at a range of information. This includes the service history for the home and inspection activity, notifications made by the home, information shared from other agencies and the general public and a number of case files. The fieldwork visit was undertaken between the hours of 9.10am and 4.45pm. 20 service users were accommodated in the home on the day of the visit. It was the assessment of the home manager that the majority of current service users had medium dependency care needs. Documentation maintained in the home was examined including staff files and training records, policies and procedures and records maintaining safe working practices. A tour of the building and several bedrooms was made. The inspector had the opportunity to meet most of the service users by spending time in the communal lounge and talked to several of them about their experience of the home. General conversation was held with other service users along with observation of working practices and staff interaction with the people living in the home. The home manager was present throughout the day. The inspectors also spoke to several care staff. The care of four service users was identified for close examination by reading their care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence of the care provided is matched to outcomes for residents. The inspector would like to thank staff and residents for their co-operation and warm welcome into their home. What the service does well: The people living in this home receive good care to meet their individual needs and have a good quality of life. It was evident that the people living in this care home feel ‘at home’ and treat the home as if it were their own. There is a cheerful and welcoming family atmosphere. Service users are at ease ‘pottering around’ and are very well supported by staff to choose how they spend their day. Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 6 The spiritual needs of the service users is a priority as the home is specifically for people from the Christadelphian community, the lifestyle provided by the home matches the preferences and values of service users. 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. Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 was assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. A pre admission assessment of the needs and ability of prospective service users is not consistently undertaken for all service users. This puts service users at risk of not receiving appropriate care. Standard 6 is not included in this judgement, as the home does not provide intermediate care. EVIDENCE: Two out of the four service users case tracked had been admitted since the last inspection. The manager told the inspector that it was usual practice for a manager from Chritadelphian Care Homes to undertake an assessment of the needs of prospective service users. The assessment is not always made by the manager of the home that the service user ultimately moves in to as applications for Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 9 accommodation in the organisation’s homes are received from all over the country. The case files of the two service users admitted since the last inspection did not contain evidence that a pre admission assessment was made before they moved into the home. This puts service users at risk of not having their needs identified and receiving inappropriate care. However, the completed application form for admission to a Christadelphian Care Home was available in the case files of both service users. The application form was completed by a representative of the prospective service user (a friend or family member) and contained some details of the needs and abilities of each individual. In addition, information had been sought from the GP of each service user and was documented in each case file prior to admission. The manager must ensure that a comprehensive assessment of the needs and abilities of prospective service users is undertaken and documented to ensure that sufficient information is available for staff to develop and implement care plans to deliver appropriate care. The manager informed the inspector that the assessment of service users’ needs is ongoing with at least monthly reviews of care and change in care plans where necessary. There was evidence of this in service users’ case files. Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 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): Standards 7, 8, 9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. The health and personal care needs of service users are met which maintains their well-being and quality of life. EVIDENCE: On the day of this inspection visit the inspector met with most of the service users. Everyone living in the home looked well cared for. All of them were appropriately dressed and special attention had been paid to individual preferences such as matching accessories to clothing or jewellery. Service users comments on the service they receive included, “I am well looked after here and well fed.” “It’s great; staff do everything we need.” and “They go along with what I want – even when it’s different to what everyone else wants.” Four service users were identified for case tracking. Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 11 Each service user had a care plan, daily records and monitoring records. Care plans are recorded on computer and printed copies are available in wellorganised individual files for each service user. Care plans were generally based on information secured during the initial care needs assessment and were developed as staff got to know the service user’s strengths and limitations. Care plans held a range of information including physical and mental capacities, nutritional needs, personal care needs, health care needs and interventions. Care plans generally supplied staff with the information needed to make sure service users needs were met safely and appropriately. Care plans were reviewed monthly. There was evidence in some of the case files that care plans are discussed and agreed with the service user. It was discussed with the manager that the limitation of reviewing each service user’s care plans on the computer each month is that new or changed needs are not documented until that time. This means that possible changes in care which occur, for example, mid month are not documented until the computerised review which means that potentially staff do not have written directions about care required for several weeks. The manager acknowledged the limitation and has given a commitment to review this. A range of risk assessments are in place for activities that may place service users at risk and include, tissue viability, falls, nutrition and mobility. There is evidence that service users have access to GP, district nurses, chiropody, optician, dentist and hospital consultants. Service users are weighed every month as part of the monitoring of their general health. Improvements were evident in the management of medicines in the home in response to the requirement made during the last inspection. A controlled drugs cabinet has been installed which meets current regulations for the safe storage of controlled drugs. The medicines trolley is now stored in a secure storeroom. Medicine keys are kept in the possession of the senior care staff member on duty. Medicines are administered by nominated staff only that have undertaken training in the safe administration of medicines. The contents of the controlled drug cupboard were audited and found to be accurate. The home uses a monitored dosage system (MDS) comprising ‘blistered’ medication for each service user which is ordered on prescription and delivered to the home each month. One of the senior care staff has a specific responsibility for the ordering and audit of medication in the home and has developed a system which ensures this is done safely and effectively each month. The medicine administration records (MAR) were examined for the four service users case tracked and audited against their individual stock of medicines. All four were found to be accurate with the MAR sheet completed appropriately. Service users were observed to be treated with respect and their dignity maintained; for example, personal care was provided in private and service Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 12 users were spoken to respectfully. Service users were observed to be at ease to call staff by their name and make requests for anything they needed. Staff were kind, caring and attentive towards them. Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. Individuals are supported to maintain a lifestyle which matches their preference and this enhances their quality of life. EVIDENCE: Christadelphian Care Homes (CCH) were set up by the Christadelphian community specifically to accommodate members of the Christadelphian Ecclesia. All of the current service users are members of the Ecclesia. The lifestyle that individuals experience in the home matches their preference in terms of spiritual values and daily life in the home has specific Christadelphian characteristics. The home is adjoined to the local Chistadelphian Hall enabling service users to access services with the local Christadelphian Community. In addition, daily Bible Readings and study takes place each evening in the ‘Quiet Lounge’ of the home. During the inspection visit service users were observed participating in several group and individual activities with the support of staff and visiting volunteers. The large communal lounge was ‘buzzing’ with cheerful activity. Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 14 Service users were observed engaging in a ‘Music and Movement’ session, reading, colouring, completing crosswords and playing board games. There was lots of ‘coming and going’ in the lounge indicating that service users are supported to choose how and where they spend their time. The inspector visited on service user in their room who commented, ‘I prefer my own quiet company but they always offer me the opportunity to take part in activities.’ Service users were observed to interact well and socialise with each other; they were sensitive to each other’s needs and abilities. There was an opportunity for one of the service users to recite some poetry they had composed which was listened to attentively by staff and service users. Service users told the inspector they can have visitors at any time and they are always made welcome. The hairdresser was making their weekly visit on the day of the inspection visit and service users enjoyed having their ‘hair done’ along with the compliments they received from their fellow residents! At 12 midday lunch was announced and service users were assisted to move to the dining area. Most service users attended the dining room but they told the inspector that they could have meals in their room if they wished. The inspector joined service users for their meal and chatted during lunch. Service users informed the inspector that there was a new system for meal service, which meant that people sat at allocated tables with their place setting indicated by a placecard. Service users said that this was successful because it meant that people were able to ‘sit with their friends’ and it removed the ‘worry’ of not being seated together. The meal consisted of roast chicken and stuffing, roast potatoes, mashed potatoes, carrots and green beans. An alternative of past or salad was offered. Menus were available on each of the tables and corresponded with today’s meal. Tables were set with tablecloths and napkins. Staff served the meat but vegetables were placed on the table in serving dishes for service users to help themselves and each other. A gravy boat and condiments were available on each table. Staff wore tabards and hats during the meal service and offered discreet and sensitive assistance where it was necessary, for example, cutting up meat. The meal was warm, nutritious, tasty and plentiful – several service users accepted the offer of ‘seconds’! Apple crumble or rice pudding was served for dessert. The meal was quite a social occasion and very pleasurable. Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. People living in the home are confident that their concerns will be listened to and acted upon and they are protected from the risk of harm from abuse. EVIDENCE: The home has a formal complaints policy which is accessible to service users. The Commission has received no complaints or concerns about this service since the last inspection. A record of compliments and complaints is maintained in the home. In practice, people living in the home talk to care staff or the manager if they have any concerns. Several service users commented that the manager and her staff were approachable, listened to their concerns or worries and acted upon them. In addition, service users have the forum of the residents’ monthly meetings where they can voice their opinion and discuss concerns. The home maintains a record of complaints and concerns raised. A notebook is kept in the reception area and service users, staff or visitors can communicate their concerns. This book was examined during the inspection and there was evidence that even what might be considered to be minor concerns are noted and acted upon. For example, one entry raised a concern about the lack of ‘crackling’ with the roast pork; an apology had been recorded along with a Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 16 description of the actions taken to rectify the situation in order that ‘crackling’ was served next time. Staff training records were seen to demonstrate that most of the staff had received training in recognising and responding to signs of abuse. It was evident through discussion with the manager that she was aware of how to respond to an allegation of abuse in the care home. In July 2006 the home informed the Commission of an allegation of abuse made by a service user. The home sought advice from appropriate agencies, which resulted in appropriate action being taken in to protect the individual. The service has recognised the opportunity to learn from the experience and have reviewed and updated it’s policy and procedure in responding to allegations or suspicion of abuse as a consequence. Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 17 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): Standards 19 and 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. The service provides a comfortable and homely environment for service users to live in and enjoy but offensive odours must be eliminated to ensure the dignity of service users. EVIDENCE: The home looks ‘lived in’; it is warm, cosy and clean with lots of the service users belongings in the communal areas. The home has one large communal lounge with an adjoining dining area and a smaller ‘Quiet Lounge’. Large windows allow for lots of natural light. People living in the home pottered around it freely making good use of both the communal and individual space. Several of the bedrooms were seen. People are encouraged to bring their own possessions into the home and personalise their rooms. The home is able to Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 18 accommodate couples in shared rooms. Without exception, all service users spoken to were happy with the accommodation provided. An offensive odour that was evident in one of the corridors was brought to the attention of the home manager. It was discussed that the management of continence of a particular service user was challenging; however, it was acknowledged that the offensive odour was unacceptable. The home has systems in place for the management of dirty laundry and the clothes of everyone living in the home looked clean, ironed and well looked after. Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 19 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): Standards 27, 28 29 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. There are sufficient competent and knowledgeable staff on duty which ensures that the identified needs of service users are met. EVIDENCE: The current usual staff complement for the home is: 8am – 2pm 2pm – 10pm 10pm – 8am 1 Senior Carer and 4 Care Staff 1 Senior Carer and 3 Care Staff 2 Care Staff (awake throughout the night shift) These staffing levels were confirmed by examination of the weekly duty rota on the day of the inspection visit and analysis of 4 weeks of duty rota supplied by the home manager prior to the visit. In addition, home manager is supernumerary and has administrative support in the office for the day-to-day running of the service. There are sufficient Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 20 catering, laundry and cleaning staff to ensure that care staff do not spend undue lengths of time undertaking non-caring tasks. The home does not use agency staff to cover absence due to sickness or holidays but uses staff overtime or their own ‘relief bank’ of staff. Staff were observed to be attentive and caring towards service users. The communal lounge was never left unattended, a staff member was always available which meant that service users were monitored and their needs attended to quickly which resulted in less frustration due to having to wait. Some of the staff are members of the Christadelphian Ecclesia which ensures that service users are cared for by people who understand their values and can support their spiritual needs. 18 out of the 19 care staff employed in the home have achieved a National Vocational Qualification (NVQ) in Care at level 2 or above which, at 95 , is well above the National Minimum Standard for 50 of staff to be qualified. This should ensure that service users are cared for by knowledgeable and competent staff. The personnel files of two recently recruited staff were examined and both contained evidence of satisfactory checks such as Criminal Record Bureau (CRB), Protection of Vulnerable Adult (PoVA) and references. However, the home was unable to demonstrate that CRB and PoVA checks were obtained before staff started working in the home. This puts service users at risk of harm from potential abuse. The manager must implement a system that ensures the necessary information is secured and staff files contain evidence that the checks were made before a person starts working in the home. Training records examined show that training is undertaken by staff and includes Fire Safety, Health and Safety, Infection Control, Safe Moving and Handling and Food Hygiene. Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 21 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): Standards 31, 33, 35 and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including visits to this service. The home is managed in the interests of service users and staff have effective leadership ensuring the needs of service users are met. EVIDENCE: There has been a change of manager since the last inspection. The new manager for the home has been in post since July 2006 and is registered with the Commission for Social Care Inspection. She is experienced in the care of older people and is appropriately qualified holding the Advanced Management in Care Certificate and the Registered Managers’ Award (NVQ Level 4 RMA). The service operates the Christadelphian Care Homes’ (CCH) Quality Assurance programme to ensure that the home is run in the best interests of service users. Records were available to demonstrate that there are monthly meetings Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 22 for service users to discuss the service they receive and to express their views. Two service users discussed this process with the inspector and commented that they looked forward to attending these meetings that were useful and informative. Trustees from CCH visit the home each month and produce a monthly report along with a welfare committee who gather the views of service users. Every six months a report is produced about the environment in the home that identifies areas requiring action to improve. All this information is gathered together in an Annual Quality Assurance report that generates an action plan to improve the service. The service has been proactive in addressing requirements made during the last inspection and makes timely and full notifications to the Commission in respect of regulations 26 and 37. Service users’ personal monies are kept securely in separate bags and accurate records of income and expenditure are kept. An audit of two service users’ personal monies was found to be correct. A selection of service records were examined to assess the home’s performance in maintaining safe working practices and demonstrates that service and maintenance of systems were carried out as follows: • • • • • The Annual Landlords Gas Safety Certificate was issued in December 2005 Annual safety checks for portable electrical appliances were made in November 2005 Records demonstrate that weekly tests of the fire alarm are not made with any consistency. The most recent certificate for checking and servicing of hoists was March 2006. These safety checks should be made 6 monthly and although the home has a contract for service and checking of this equipment there was no certificate available to confirm that it had been undertaken when it was due in September 2006. The home’s nurse call system was serviced in August 2006 Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 23 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 2 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14 Requirement Timescale for action 31/12/06 2 3 OP26 OP29 13 19 The registered manager must ensure that the needs of prospective service users are assessed and documented before they are provided with accommodation in the home. The registered manager must 31/01/07 ensure that all areas of the home are free from offensive odours. The registered provider must 31/12/06 ensure that satisfactory preemployment checks such as Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (PoVA) are obtained and the evidence documented in staff files before a person starts work in the home. 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 Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Peacehaven DS0000004229.V308670.R01.S.doc Version 5.2 Page 27 - 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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