CARE HOME ADULTS 18-65
Peacehaven 43a Maldon Road Tiptree Colchester Essex CO5 0TS Lead Inspector
Neal Wolton-Harragan Unannounced Inspection 22nd December 2005 10:30 Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 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 DS0000017905.V277846.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 Adults 18-65. 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 DS0000017905.V277846.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Peacehaven Address 43a Maldon Road Tiptree Colchester Essex CO5 0TS 01621 818220 01621 818220 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) Mrs Patricia Anne Payne Mrs Patricia Anne Payne Care Home 3 Category(ies) of Learning disability (3), Physical disability (1) registration, with number of places Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 3 persons) One person, under the age of 65 years, who requires care by reason of a learning disability, who also has a physical disability, and who has resided in the home since April 2002 The total number of service users accommodated must not exceed 3 persons 25th November 2004 Date of last inspection Brief Description of the Service: Peacehaven is a home accommodating 3 individuals with learning disabilities, one of whom also has physical disabilities. The home is a semi-detached property, close to Tiptree town centre. The Proprietor/Manager of the home is Mrs Patricia Payne who has run the home prior to registration under previous legislation in 1994. Service users are offered accommodation within the family home, consisting of one downstairs bedroom and two further bedrooms upstairs. A lounge dining area and kitchen are shared with the family. There is a small, enclosed garden area to the rear of the property, accessed through patio doors at the end of the dining area. Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report follows an unannounced inspection at Peacehaven, on December 22nd 2005, the first inspection of the home for the year 2005/06. During this inspection, 34 of the 43 standards were looked at; 29 were met, 4 were nearly met and one was unmet. The owner and Registered Manager, Mrs Patricia Payne, was not in attendance on the day of the inspection, although her daughter and Assistant Manager, Mrs Alison Strachan, was available throughout the inspection and contributed fully to the inspection process. As reported at previous inspections, the service users at Peacehaven are offered care within the proprietor’s own home. This means that whilst legally a care home, the nature of the care offered on a day-to-day basis is more in line with an adult placement. At this inspection, it was suggested to Mrs Strachan that she investigate the possibility of becoming affiliated to an Adult Placement scheme as this might more appropriately suit the needs of Peacehaven and those living there. Shortfalls identified by this inspection do not reflect the level or quality of care received on a daily basis, but are due, in part, to the nature of the way the care is offered. However, concerted efforts are being made in the home to meet the regulatory requirements. There remains the stated intention for Mrs Strachan to take over managerial responsibility for the home and to undertake NVQ level 4 Care and Management training and she is, as previously reported, taking a lead role in the day-to-day running of the home. Both Mrs Strachan and Mrs Payne are aware that until Mrs Strachan is registered as the manager, managerial responsibility remains with Mrs Payne. What the service does well:
Peacehaven was well managed. Staff had a good understanding of their roles and responsibilities and the home had a positive attitude towards staff training. The service users are treated as family members and consequently good quality care is provided in a homely environment. Those living at Peacehaven were encouraged to maintain positive relationships with their families. Service user records showed that people living at Peacehaven were consulted on all areas of life at the home and supported to make decisions about how they would live their lives. All those living at the home had full and varied lives, taking part in education and leisure activities throughout each week. Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 6 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 DS0000017905.V277846.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Prospective service users’ individual aspirations and needs would be assessed. Each service user had an individual written contract with the home EVIDENCE: Those living at Peacehaven have done so for many years. There have been no recent admissions nor are there plans for others to enter the home. Should a new service user come into the home, records and discussions with the Assistant Manager suggested that needs would be fully assessed prior to admission. Since the last inspection, all service users have been issued with individual, written contracts and statements of terms and conditions with the home. Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Service users’ assessed and changing needs were reflected in their individual plans. Service users were involved in the decision-making process in all aspects of their lives. Service users were supported to take risks as part of an independent lifestyle. EVIDENCE: The service user records sampled during the inspection showed that individual needs were assessed and were reflected within individual service user plans. These plans were subject to regular monitoring and review, and changes in needs were identified and acted upon. The examination of records and discussions with individual service users and staff gave evidence that service users were central to the decision-making processes within Willow End, as well as playing a pivotal role within care reviews. Individual service user records showed that thorough risk assessments had been undertaken and risks were managed and reviewed appropriately. It was also apparent, from the examination of records and conversations with the service user at home on the day of inspection, that service users at Peacehaven knew and understood the contents of their individual plans.
Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Service users had opportunities for personal development and were able to take part in age, peer and culturally appropriate activities. Service users were active members of the local community, engaged in appropriate leisure activities and had appropriate opportunities to develop and maintain personal and family relationships. Service users’ rights were respected and responsibilities recognised in their daily lives. EVIDENCE: The service user records examined gave evidence that each person living at the home had a detailed weekly programme that included education and leisure type activities. The service user spoken with on the day of inspection stated that they used community facilities as part of their daily lives and enjoyed the activities on offer, although at present her activities were limited following an accident earlier in the year. Discussion with service users and staff, as well as the examination of records, showed that service users’ rights were respected and appropriate personal
Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 11 relationships supported. Service users had regular and positive contact with their families where appropriate. One service user’s bedroom was kept locked during the day in response to behaviours. The service user’s individual records showed evidence that a thorough risk assessment had been completed and there was acknowledgement that this person’s rights were being infringed by this restriction, although it was part of an overall management strategy. Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users received personal support in the way they preferred and required, and physical and emotional health needs were met. No service users retained, administered or controlled their own medication at the time of this inspection. Service users were protected by the homes policies and procedures for dealing with medicines. EVIDENCE: The service user spoken with was happy with the way they were supported and this was reflected within their individual plan, as well as in other service user plans examined. Service user plans identified individual needs, as well as how the service user would like these needs to be met. Care plans were well detailed, regularly monitored and formally reviewed at intervals depending on individual need. There was an ongoing process of assessment to take account of the changing needs of individuals. The services of healthcare professionals, such as community nurses, speech and language therapists or psychologists, were accessed as where needed. None of the service users retained, administered or controlled their own medications at the time of this inspection. Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Arrangements were in place to help protect service users from abuse, neglect and self-harm. Service users felt their views were listened to and acted upon. EVIDENCE: The home had a robust complaints procedure and abuse policy. However, there was a need to amend these documents to show the contact details of the Commission for Social Care Inspection. The adult protection policies and procedures were adequate to protect service users from abuse and where service users presented with behaviours likely to cause self-harm, these behaviours were identified within their care plans and management strategies devised. Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 & 30 The home was generally comfortable and safe service users’ bedrooms suited their needs and lifestyles and promoted independence. There was adequate shared space to meet the needs and numbers of service users. The home was clean and hygienic throughout. Hot water temperatures were at a dangerous level. EVIDENCE: Care is provided within the family home of the proprietors of Peacehaven and is very much of a domestic style. Individual rooms were furnished to an appropriate level and new furniture and carpet had been installed in one bedroom. Individual bedrooms suited service user needs and lifestyles, were decorated to the colours of the service users’ choice and promoted independence. Mrs Strachan advised that there were plans to redecorate the whole of Peacehaven, following the installation of a new kitchen and new windows and doors. There are also plans to fit new carpets throughout. The delivery temperature of hot water to both the ground floor and first floor bathrooms was in excess of 60°C and required immediate attention. Mrs
Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 15 Strachan contacted the plumber while the Inspector was still at the home and got assurances that the issue would be dealt with that day. The Registered Person must provide evidence to the Commission for Social Care Inspection that corrective action has been taken to ensure the delivery of hot water at around 43°C. Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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, 32, 34, 35 & 36 Service users benefited from clear staff roles and staff received training to meet the individual and joint needs of service users. Service users were supported by competent staff and largely protected by the homes recruitment policies and practices. Staff were adequately supported and supervised. EVIDENCE: There have been no staff appointed since the last inspection and most of the care provided is by Mrs Payne, the Registered Manager, or Mrs Strachan, the Assistant Manager. There were a small number of carers employed at Peacehaven and these staff received training earlier in the year covering Moving and Handling, Basic First Aid, Basic Food Hygiene and Health, Safety and Fire Awareness. Further training was planned for the coming year with Moving and Handling updates programmed for March 2006. The home has improved the records kept in relation to care staff, with all the information and documentation required under the Care Homes Regulations 2001 in place, with the exception of Criminal Records Bureau disclosures, although Mrs Strachan advised that these had been applied for at the time of the inspection. Since the last inspection a system of staff support and supervision had been introduced and appropriate records were being maintained.
Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 42 & 43 The home was well run and service users benefited from the ethos, leadership and management approach of the home. Service users’ rights and best interests are safeguarded by the home’s policies. The health, safety and welfare of service users were not completely promoted and protected. The home was working through a process of quality monitoring. EVIDENCE: It was apparent at the inspection, from observation of interactions between staff and service users, that there was an open and inclusive management culture at the home and relationships between staff and service users were very positive. Records showed that regular staff meetings were being held and service users’ views were sought and taken into account when planning activities, events or developments within the home. As previously stated, the temperature of hot water at both the first and ground floor bathrooms was excessive and remedial action was required to protect the health and safety of the service users. There was no certificate of insurance at
Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 18 Peacehaven on the day of inspection, although Mrs Strachan believed insurance cover had been arranged and agreed to send a copy of the certificate to the Commission for Social Care Inspection. Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 X 1 2 Peacehaven DS0000017905.V277846.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 YA22 Regulation 22(7) Timescale for action The Registered Person must 10/03/06 ensure that the home’s complaints procedure is revised to show contact details of the Commission for Social Care Inspection. The Registered Person must 10/03/06 ensure that the home’s abuse policy is revised to show contact details of the Commission for Social Care Inspection The Registered Person must 22/12/05 ensure that the environment is safe for service users. This refers specifically to ensuring the temperature of hot water delivered to baths is maintained at around 43°C. The Registered Person must 01/03/06 ensure that Criminal Records Bureau enhanced disclosures are received in respect of all care staff working at the home. The Registered Manager must 01/03/06 ensure the provision of insurance in respect of liability that may be incurred by them in relation to the home. The previous timescale of 28th February 2005 was not met.
DS0000017905.V277846.R01.S.doc Version 5.1 Page 21 Requirement 2 YA23 13(6) 3 YA24 YA42 13(4)(a) & (c) 4 YA34 19, Schedule 2 13 5 YA43 Peacehaven 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 DS0000017905.V277846.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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