Inspection on 27/03/07 for Peacehaven

This inspection was carried out on 27th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 14/02/06

Peacehaven 28/07/05

Peacehaven 04/01/05

Peacehaven 04/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Peacehaven 101 Roe Lane/1a Derwent Avenue Southport Merseyside PR9 7PD Lead Inspector Mrs Margaret Van Schaick Unannounced Inspection 27th March 2007 09:30 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.V334143.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 DS0000005352.V334143.R01.S.doc Version 5.2 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 55 Category(ies) of Old age, not falling within any other category registration, with number (55) of places Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 55 Old Persons The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 14th February 2006 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 55 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 55 single bedrooms placed on two floors. 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 five 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. New footpaths have recently been completed for residents use. 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. Weekly fees are £361.50-£375. Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days and lasted ten hours. This was the key unannounced inspection to be carried out as part of the regulatory requirements. As part of the inspection process most areas of the home were viewed including some of the residents bedrooms. Resident care records and other care home records were inspected also. Discussion took place with the manager, deputy manager and some care staff. Two care staff were interviewed on a one to one basis. Several residents were also spoken with and three were interviewed in private and their views obtained on how the home was run. One relative was interviewed in private. Have your say about……questionnaires were sent out to the residents by the Commission prior to the inspection. These have been completed and returned and their views are included in this report. Health professionals who visit the home regularly were also contacted for their views and their comments are included in this report. What the service does well: Residents are assessed prior to admission therefore this ensures residents needs are identified. Peacehaven offers prospective clients the chance to meet other residents and staff by inviting them to the home for a few hours prior to admission. Residents’ healthcare needs are identified and met to residents’ satisfaction. Relatives interviewed stated, “the home have done brilliantly, we couldn’t have asked for better care”. Residents interviewed stated, “ I’m happy with the care, quite happy” and “we are very well looked after, I don’t think there is anywhere in Southport as good as this”. The home provides a setting that encourages individual choice and preferences including a range of activities suitable to accommodate individual residents needs. Residents interviewed stated, “I still attend the quiz tournament and we have won the last three, we go to another home on Wednesday this week”, “I have been making cards and playing bowls in the big lounge recently”. Other residents interviewed confirmed that they enjoyed the activities arranged in the home, stating, “there is always lots going on”. Residents are provided with a nutritious and appealing diet. Residents interviewed stated, “my daughter visits me, they are very good with visitors and are given a cup of tea”, and “visitors have a tray of tea”, “the food is Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 6 excellent, I’m putting on a lot of weight and the kitchen staff are lovely” and “they always find you something if you don’t like what is on the menu”. The open culture in the home encourages residents and staff to make known any concerns. The homes complaints process is understood and known to the residents. Residents interviewed confirmed that they were aware of the complaints procedure, stating, “if I’m not happy I go straight to the top and Lyn (manager) resolves the problem”. Other residents interviewed stated, “I have no complaints, if worried, I can talk to Ray (deputy) or Betty (senior carer). The home provides a safe and well-maintained environment for residents. The home was clean throughout during the inspection visit. Feedback from residents also confirmed that they are happy with their individual bedrooms and public areas. Residents interviewed stated, “visitors who have come to see me have remarked on the cleanliness”. The home provides sufficient and well-trained staff to support the needs of the residents. The home has exceeded the standard with regard to NVQ training. Comments received from residents include “the staff are one of the reasons for the happy atmosphere prevailing here” and “visitors that have come to see me have remarked on the happy atmosphere”. The home provides a well-managed service for residents and staff. Residents interviewed stated, “If you ask you can see Lyn (manager) if troubled, she’s very good”. Staff interviewed stated, “the manager is approachable” and “Lyn is marvellous, very approachable”. What has improved since the last inspection? What they could do better: Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 7 The management of medications needs to be monitored on a regular basis to ensure that any discrepancies are picked up on and resolved quickly. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents are assessed prior to admission therefore this ensures residents needs are identified. This judgement has been made using available evidence including a visit to this service. OP 3 and 6 were assessed. EVIDENCE: Four residents files were case tracked. All of the files examined evidenced full assessments were carried out prior to admission. Where possible residents are invited to spend a few hours in the home prior to admission so that prospective residents can meet with the residents and staff and become familiar with the home and how it is run. This is good practice. This enables prospective residents to make an informed choice. It also enables staff to further assess prospective residents needs. Residents interviewed stated, “my sons chose this place, I was brought to see it, I thought it very nice” and “I knew this home as I’d visited it years ago”. Through discussion other Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 10 residents confirmed that they had viewed the home prior to admission. One resident commented, “I was shown round with a senior care assistant who explained things to me and offered choices of rooms”. The assessment documentation evidences previous medical history, personal details, preferred name, risk assessments, inventory, waterlow scores (tool to measure risk of developing pressure sores), nutritional assessment, manual handling assessment and 24 hour care needs. A kitchen notification form identifies likes and dislikes and the Chef meets with the new residents to further assess their nutritional requirements. An assessment of the residents proposed bedroom is carried out to ensure it is suitable and further equipment identified as necessary is then put in place. The home has 5 intermediate beds. Residents admitted under the Intermediate Care Team evidence copies of their assessment carried out by the PCT (Primary Care Team). Copies of these were viewed. The dischargeplanning nurse carries out an assessment of the prospective residents needs and each assessment is signed and dated. These are then faxed to the home prior to admission. An occupational therapist report is in place also. Residents admitted for intermediate care are under the medical care of a named GP and care is planned and monitored by the intermediate care team throughout their stay. Intermediate care staff visited several times during the inspection visit. The residents are also supported and cared for by staff in the home on a daily basis. Health professionals were canvassed for their views on how the home was managing the needs of the residents admitted for intermediate care. Health professionals interviewed stated, “there can be a problem with communication, we do have regular discussions with senior staff with regard to residents care but this does not always get communicated throughout the intermediate care unit”. Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Resident’s healthcare needs are identified and met to residents’ satisfaction. This judgement has been made using available evidence including a visit to this service. OP 7,8,9 and 10 were assessed. EVIDENCE: Four residents care plans were viewed and all evidenced that the care needs identified on the assessment documentation had been addressed. Care plans are set up on admission to the home. Through discussion with senior staff it is apparent that following the first few weeks of admission, care plans are added to and updated as the residents needs become more apparent. Care plans evidence regular reviews throughout the residents stay with the most recent carried out in March 2007. Care plans have been agreed and signed by the resident. Referrals have been made to other health professionals and their visits have been recorded in the individual files. Any new treatment/medication prescribed is evidenced in the professional visit records. Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 12 Other health professional visits such as opticians/dentists/chiropodists are kept for all residents on a separate file and archived in their individual records. Residents who receive District Nurse input have separate records kept of prescribed treatment and up to date progress. There is also evidence of other health professional visits identifying that the residents’ needs are being well managed in the home and they have now been discharged from the specialist nurse. Relatives and residents canvassed for their views on how the home manages residents’ healthcare needs gave positive responses. Relatives interviewed stated, “the home have done brilliantly, we couldn’t have asked for better care”. Residents interviewed stated, “ I’m happy with the care, quite happy” and “we are very well looked after, I don’t think there is anywhere in Southport as good as this”. Dependency levels are identified and manual handling assessments are in place with reviews on a regular basis. Weights and heights are checked on admission. Risk assessments are in place with regard to residents’ mobility, bed, bath and wheelchair use and the internal and external environment. Significant life events, occupational history, hobbies and wartime history where appropriate are recorded. Personal routines are identified and addressed in the care plan such as getting up times and bath/shower preference. Due to the risk of falls, residents are checked at night on an hourly basis. Chiropodists visit the home 6 weekly and their visits are logged in the daily evaluation. Some residents have their own chiropodists and this is accommodated. Residents have a lockable facility in their bedrooms for storage of medication or other items. A list of staff trained to administer medication is available with their signatures/initials evident. New training is about to take place with the homes local pharmacist. Previous medication training is also highlighted. A new lockable medication storage room is in place and locked medication trolleys are secure in this room. A medication fridge is in place with regular temperature readings in place. The home has a returns book but it had been sent to the chemist therefore was not viewed. Much of the medication is in blister pack. The medication room and trolleys were locked and organised. One of the medication sheets checked did not record the amount of medication in stock. The registered manager explained that a resident had recently come into the home with additional medication, which had resulted in their not taken the prescribed course. The manager arranged for the pharmacist to visit the home to offer advice. This advice has been taken up and the residents medication is now resolved. Medication data is kept. One of the residents’ medication record evidences Warfarin is administered. The Warfarin dose shows 1mg yet the amount given is 2mg. The manager advised that following a visit to the Haematology clinic the dose was changed therefore the home should identify this on the medication record. Controlled medication records are kept and one resident’s supply was checked as accurate. The records show that some errors had been made with regard to the total stock carried forward but it was clear to see the error and on checking this, the amount of medication was Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 13 accounted for. It is recommended that the manager audit the medication records so that any errors can be picked up at an early stage and resolved. Residents interviewed confirmed that staff always knocked prior to entering their bedrooms. Residents interviewed confirmed that they were able to lock their bedroom doors with their own key. Through discussion with residents it is apparent that they are happy with the how the home cater for their needs and confirm health professional support/advice is provided where needed. Residents interviewed stated, “If you have got to be anywhere this is the place to be, I’m definitely happy with the care”. Two relatives have been so pleased with the care and support provided by the home that they have personally written in to the Commission to advise them of this. Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home provides a setting that encourages individual choice and preferences including a range of activities suitable to accommodate individual residents needs. Residents are provided with a nutritious and appealing diet. This judgement has been made using available evidence including a visit to this service. OP 12,13,14 and 15 were assessed. EVIDENCE: Care files evidence that residents are asked about their daily routine. Residents interviewed confirmed that they have choices with regard to getting up, retiring to bed, using the bath or shower and how they like to spend their time. Residents interviewed stated, “you can go to bed and get up when you want to”. Residents confirmed that the home respect the wishes of the residents who prefer same sex carers to assist with personal care. The home employ activities personnel who plan many suitable activities for the residents. This is good practice. Regular meetings are held throughout the year to discuss any outings/venues that residents would wish to visit and various activities are planned. Other activities are planned on a daily basis with most of the residents participating each day. Residents who do not wish to Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 15 participate in activities have their wishes accommodated. Activities are advertised on the residents’ board. Residents interviewed stated, “I still attend the quiz tournament and we have won the last three, we go to another home on Wednesday this week”, “I have been making cards and playing bowls in the big lounge recently”. Other residents interviewed confirmed that they enjoyed the activities arranged in the home, stating, “there is always lots going on”. One resident interviewed stated, “I spend a lot of my time walking in the garden and in summer we go on a barge boat, it’s pretty good for entertainment, we do jigsaws and paint pots too”. Residents’ religion is recorded on care documentation. Through discussion with residents it is apparent that religious needs are met, residents confirmed that they receive Communion every Sunday. Residents confirmed that their families and friends are encouraged to visit the home when they wish. Residents interviewed stated, “my daughter visits me, they are very good with visitors and are given a cup of tea”, and “visitors have a tray of tea”. Through discussion with residents it is apparent that some of their relatives have meals with them when wished. This is good practice. Some of the nutritional assessments were checked and all evidenced they were fully completed therefore the previous requirement has been met. The menu is on display on the residents’ board in the front hall. The menu is planned on a four weekly rota and is reviewed regularly throughout the year with a seasonal emphasis. There are choices for starters, main courses and puddings. Residents in general were very happy with the meals served in the home. Residents interviewed stated, “poor food at present, not getting enough nourishment” and “the food has been quite nice, they always find you something if you don’t like what is on the menu”. Other residents interviewed stated, “I can have what I want in the evening, I usually have something different from the menu” and “there is a substantial choice in the evening”. Relatives interviewed stated, “I am happy with the food”. A new senior chef is about to commence therefore hopefully any concerns raised by residents will be discussed and resolved. Staff interviewed stated, “residents who wish are woken up at 6.30 with tea and a biscuit, at about 10.15 tea/coffee and biscuits, 3pm tea and biscuits, 8pm horlicks or other drinks with sandwiches, biscuits, crackers and at 10pm a trolley goes round for residents who wish to have another drink”. Residents interviewed confirmed that they were offered refreshments between meals and stated, “if we want to we can have a cup of tea from the night staff”. Other residents interviewed stated, “the food is excellent, I’m putting on a lot of weight and the kitchen staff are lovely” and “they always find you something if you don’t like what is on the menu”. Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The open culture in the home encourages residents and staff to make known any concerns. The homes complaints process is understood and known to the residents. This judgement has been made using available evidence including a visit to this service. OP16 and 18 were assessed. EVIDENCE: The homes complaints procedure is in the front hall, the staff room and in residents’ handbooks. Residents interviewed confirmed that they were aware of the complaints procedure, stating, “if I’m not happy I go straight to the top and Lyn (manager) resolves the problem”. Other residents interviewed stated, “I have no complaints, if worried, I can talk to Ray (deputy) or Betty (senior carer). The complaints log was viewed and identified complaints raised within the home. The manager carries out an investigation and the results of this and the outcomes are logged separately to maintain confidentiality. The manager keeps the Commission informed when needed. Through discussion with residents and staff on the inspection visit all have confidence that any of their concerns would be listened to and acted on. One resident interviewed stated, “we have a complaints and praise system”. The minutes of previous meetings were viewed and showed that residents are able to discuss any items including Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 17 preferred food requests. Residents committee meetings were also viewed and areas discussed included new furnishings, teaspoons missing, gravy too thin and activities feedback. A whistle blowing policy is in place with copies in the staff room and kitchen. The manager has downloaded the new Sefton Abuse policy. The manager has attended an abuse awareness course and the deputy manager provides small workshops to provide training through videos and discussion on a regular basis. Staff interviewed were able to discuss abuse awareness and were knowledgeable about the varying forms of abuse and were confident that they would alert a senior member of staff if concerned. Residents have a lockable cupboard in their bedrooms with the residents holding the key. Financial records are kept for residents ‘monies’. The records show the outstanding amount, withdrawals and deposit amounts entered. The reasons for withdrawals are recorded and receipts and small amounts of money are kept in individual ‘money bags’. Signatures are in place and the manager spot-checks six weekly. A valuables book is in place. Sefton advocacy details of contact are identified on a poster format. Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home provides a safe and well-maintained environment for residents. This judgement has been made using available evidence including a visit to this service. OP19 and 26 were assessed. EVIDENCE: A tour of the home took place including some of the residents’ bedrooms. The home is well laid out with wide hallways, which ensures easier access for residents. A lift is in place to the upper floor and handrails are in place throughout the home. The home is well maintained and the inspector viewed the maintenance and planned programme for refurbishment/improvements identified including an upgrading of the kitchen facilities in Derwent wing. The planned improvements included internal and external areas. One resident interviewed stated, “I’ve been told that I’m having my room redecorated soon” Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 19 and other residents in the home confirmed through discussion that they were very happy with their individual accommodation. During the tour of the home it is evident that a high standard of cleanliness is maintained. Feedback from residents also confirmed that they are happy with their individual bedrooms and public areas. Residents interviewed stated, “visitors who have come to see me have remarked on the cleanliness”. The home has a laundry room, which was clean and well organised during the visit and is sited well away from the kitchen and dining areas. Suitable washing/drying facilities including a foul laundry capacity are in place. Hand washing facilities are placed throughout the home. Externally the home is well maintained and the garden grounds are large, full of various shrubs and flowers. Residents are able to access the gardens and a new path has just been laid out so that residents can access the new summerhouse. Residents interviewed stated, “I spend my time walking around the garden”. Suitable garden furniture is placed around the garden for residents and their visitors to enjoy. The home has a therapy room specifically for residents who spend short stays (intermediate care) in the home. There are facilities for the purpose of preparing refreshments and snacks. A separate hairdressing salon is in use and provides facilities for six hairdressers at present. Many of the residents have their own hairdresser. Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. That the home provides sufficient and well-trained staff to support the needs of the residents. This judgement has been made using available evidence including a visit to this service. OP27,28,29 and 30 were assessed. EVIDENCE: The staffing rota was viewed and evidenced sufficient staff is employed to manage the home effectively. Four ‘waking’ care staff are on duty throughout the night. 70 of care staff are qualified to NVQ Level 2 or above therefore this standard is exceeded. Five staff files and training records were examined. All staff files evidence completed application forms with educational and employment history. Personal details, medical questionnaires, letter to confirm offer of employment with start dates are in place. Two written references are in place. Policies re gifts from residents, training contract and employment contracts are signed and in place in all files. Staff supervision/appraisals carried out is evidenced in some staff files. CRB (Criminal Record Bureau) and POVA first (Protection of Vulnerable Adults) are in place for all staff. Training attended includes health and safety, first aid, basic food hygiene, manual handling, fire training, infection control, NVQ Level 2 and for some Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 21 more senior staff NVQ Level 3 and 4. The manager and a senior carer also set up fire training with the night staff throughout the year at a more suitable time in the evening. Other training attended includes Dementia, Diabetes, elder abuse, death and dying and management of strokes. The deputy manager also runs ‘workshops’ most Wednesday afternoons for staff, covering various aspects of care. This is good practice. New staff induction lasts six weeks and staff are supervised during this time. Staff interviewed confirmed they had received an induction. Through discussion with residents it is apparent that they like the staff that look after them. Residents interviewed stated, “I see Betty (senior carer) regularly but I don’t see enough of the staff so that we can have a chat”, “care staff on the whole are very good, they are very kind to me”, “if you ring the bell for them they are there in a minute or two” and “staff are very nice”. The Commission also canvassed residents for their views on how the home was run and comments received included, “the staff are one of the reasons for the happy atmosphere prevailing here” and “visitors that have come to see me have remarked on the happy atmosphere”. Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. The home provides a well-managed service for residents and staff. This judgement has been made using available evidence including a visit to this service. OP31,33, 35 and 38 were assessed. EVIDENCE: The registered manager has been in post for almost 4 years. The manager has also worked at the home as the administrator prior to appointment as the registered manager. The manager has kept herself up to date by attending various courses including all mandatory training, medication reviews and abuse awareness. The manager has recently gained the Registered Managers Award in December 2006. Through discussion with residents and staff it is apparent that the manager is approachable and spends time with the Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 23 residents. Residents interviewed stated, “If you ask you can see Lyn (manager) if troubled, she’s very good”. Staff interviewed stated, “the manager is approachable” and “Lyn is marvellous, very approachable”. The manager is responsible for Peacehaven only. Through discussion with the manager and senior staff it is apparent that they are familiar with and knowledgeable about the varying conditions/illnesses of the residents that are cared for in the home. Effective quality assurance and monitoring systems are in place. The home has gained an external quality assurance award. One of the residents commented, “Peacehaven have been five star rated”. Residents and relatives are canvassed for their views throughout the year and views are taken into consideration and acted on where possible. Residents meetings are held six weekly, care staff meetings three monthly, activities meetings three monthly, senior staff meetings six-eight weekly, kitchen staff meetings eight weekly, Minutes of these meetings are published, some of which were viewed during this visit. Minutes of residents meetings are published and passed around the home with copies displayed in the conservatory and main lounges. Praise and complaints meetings are also held regularly with residents able to raise issues including loud televisions and praising staff. The Commission canvassed residents’ views through questionnaires prior to the inspection visit. The response from these and other residents/relatives feedback is positive. Residents’ comments include, “this home is well run by ‘trained’ staff, who are friendly and patient with everyone”. Any minor issues that residents have raised are addressed to the residents’ satisfaction. The ‘Friends of Peacehaven’ (fund raising committee) meet regularly (3-4 monthly). The Trustees (Directors of Peacehaven) meet bi-monthly to discuss issues with regard to the management of the home. There is an annual development plan for the home. Through discussion with residents it is apparent that they are kept informed of any changes/improvements being made in the home. Policies and procedures are regularly updated throughout the year. Resident’s monies and financial records have already been addressed in an earlier part of this report. Safe working practices are in place as staff are updated throughout the year on mandatory training. Training attended includes, basic food hygiene, health and safety, first aid, manual handling, infection control and fire safety. Hazardous substances are stored securely. Hot water temperature checks are carried out weekly and the most recent water heating check for compliance with Legionella was in August 2006. Regular servicing of gas boilers and systems, electrical systems and equipment are up to date with certificates held. Window restrictors are in place throughout the home. The manager is aware of RIDDOR (Reporting of Disease and Dangerous Occurrences Register). Risk assessments are in place. Accident records are Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 24 completed clearly. Safety posters are in evidence. New staff receive a sixweek induction as confirmed through discussion with staff. Fire equipment checks are up to date also with the most recent in January 2007. Fire alarm tests are carried out weekly. Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 25 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 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 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP9 OP9 Good Practice Recommendations The inspector recommends that the manager should carry out regular audits of the medication and documentation relating to medication records. The inspector recommends that when Warfarin dose is changed following a clinic appointment the new dose should be entered on the current medication sheet. The inspector recommends that when a new resident is admitted to the home that medication should be checked out thoroughly and confirmed by their GP where necessary. Peacehaven DS0000005352.V334143.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000005352.V334143.R01.S.doc Version 5.2 Page 28 - 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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