Inspection on 28/07/05 for Peacehaven

This inspection was carried out on 28th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 27/03/07

Peacehaven 14/02/06

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/ 1 Derwent Avenue Southport Merseyside PR9 7PD Lead Inspector Paul Kenyon Unannounced 28th July 2005 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 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 F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Peacehaven Address 101 Roe Lane/ 1a Derwent Avenue Southport Merseyside PR9 7PD 01704 227030 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Peacehaven House Mrs Lynne Nuttall Care Home 52 Category(ies) of Old Age - 52 registration, with number of places Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 52 Old Persons. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commision forSocial Care Inspection. Date of last inspection 4th January 2005 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. Refurbishment of one part of the property has reduced this to 52 beds yet includes provision of en suite facilities. This refurbishment to the part of the home known as Derwent is virtually complete. A passenger lift provides access to upper floors. The home offers intermediate care to five persons.All the bedrooms have pleasant views of the gardens. Communal space currently provides 3 sitting rooms, 2 dining rooms and a conservatory. There is also a smaller lounge that acts as a designated smoking area.The home has currently two ramps in place, which enable service users to access the grounds from the front and side doors, with garden furniture suitable for use by service users and their visitors. The home has a variety of hoists and suitably adapted equipment to assist with the varying needs of service users. There is also a call bell system throughout the home including all bedrooms. Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four and a half hours and coincided with the late morning and early afternoon periods. The inspection included a tour of the building, discussions with five residents and the examination of various records. What the service does well: What has improved since the last inspection? What they could do better: Assessments undertaken for prospective residents are not always dated. The result of this is that it is difficult to determine whether residents are having their needs assessed before they come to live in Peacehaven. In addition to this, the management team needs to provide evidence that the building’s gas systems are being checked every twelve months and that potable and fixed hoists are being serviced every six months. Recommendations are raised in respect of weight monitoring and information about resident routines for staff. Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 6 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 F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 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 standard(s) 3 and 6 Assessments are conducted on all prospective residents yet there is no evidence that these are obtained prior to admission in all cases. Those residents receiving intermediate care have their needs met. EVIDENCE: A total of four assessments relating to newly admitted residents were viewed. These assessments contain information on the individual’s needs and these are translated into care plans. Assessments were available from Funding Authorities as well as the home’s own assessments. In the case of home assessments, these were not always dated. Assessments outline the reasons for admission, a summary of the physical needs of residents, a risk assessment as well as mental health and nutritional assessments. The home provides support for a number of individuals who are receiving intermediate care. The aim for these individuals is that they will return to their own homes after a period of support from the home and a number of external professional agencies. The care plans of three individuals were examined. In these cases there was evidence that external agencies such as Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 9 physiotherapists and district nurses visit on a daily basis to offer the support they need to return to their own homes. The home offers them accommodation yet exclusively external professionals provide support. Examination of care documents suggested that their needs are met. Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 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 standard(s) 7,8 and 9 Care plans set out the health, personal and social needs of residents. The health needs of individuals are fully met. A good practice issue is raised in this report about the frequency of weight monitoring. Medication systems are safe and enable a degree of independence for those who wish to administer their own medication. EVIDENCE: A total of four care plans were examined. In all cases, care plans had been reviewed at least on a monthly basis. The review includes a signed agreement from residents or their representatives. From time to time it is necessary to redevise the care plan to reflect changes in the resident’s needs. This is also subject to residents’ agreement and this was in evidence. Care plans include reference to the health needs of residents as well as consideration in all cases to their social needs. Health records are maintained within care plans. All residents are registered wit a General practitioner. Care plans include reference to the health needs of residents and this is accompanied by a list of appointments that have been attended to General Practitioners, hospital visits and other interventions by medical professionals. The psychological health of residents is taken into Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 11 account through the use of an initial mental health assessment. In some cases, it is necessary for the intervention of community nurses to assess mental state. Care plans also outline the action staff need to ensure that these needs are being met. All residents have their susceptibility to pressure sores assessed and nutritional assessments are also carried out. The weight monitoring of individuals is carried out but has tended not to be recent. It is recommended that this be carried out more regularly. The health needs of intermediate care residents is met through the daily interventions by medical professionals outlined in their plans of care. Medication is securely stored in a designated area that is locked when not in use. A monitored dosage system is in operation and all medication records are correctly signed after administration. Some residents administer their own medication. Risk assessments are in place for these individuals and these are reviewed regularly. All medication received is recorded and a disposals book is also in operation. Training for all senior staff who administer medication is to be updated. Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 Residents benefit from a comprehensive activities programme and residents confirmed that routines are flexible. A good practice recommendation is raised in this report in respect of timing and arrangements for bathing residents. EVIDENCE: Activity organisers are employed by the home and there is a schedule of activities that take place over a few weeks. Activities include reference to in house events as well as outings to local places of interest. A schedule of activities is available with notice boards on display in all living areas outlining those activities that are to take place that day. Residents confirmed that they had taken advantage of recent outings to a local pub. Some residents stated that they did not pursue activities yet felt that ‘this preference is respected’. All residents were able to confirm that daily routines were flexible and that they could rise or retire when they wished. Mealtimes tended to be set yet they understood that ‘they have a lot of people to cater for’. A schedule for the bathing of residents was available as well as information within care plan reviews. The wording of this information did not indicate that flexibility, as confirmed by residents, was offered. It is recommended that the wording of such documents be changed to enable staff to understand that residents’ preferences should be taken into account. Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 13 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 standard(s) 16 and 18 Residents have access to a clear complaints procedure. Residents are safeguarded form abuse through the policies and procedures available within the home. EVIDENCE: All residents who offered views during the visit stated that ‘I haven’t had to make a complaint but I know what to do’, ‘I feel confident that my views would be listened to’ and that’ staff would sort it out’. No complaints have been received by the Commission For Social Care Inspection although one complaint has been referred to the home’s own complaints procedure. Evidence was available that this had been recorded and that details of the investigation’s outcome had been carried out within timescales outlined in the complaints procedure. The home has an adult abuse policy as well as a Local Authority abuse referral procedure. These are available to staff at all times. The whistle blowing procedure is available and includes reference to the Commission For Social Care Inspection for the reporting of concerns. The whistle blowing policy is on display for staff in key areas of the home such as the main office and staff room. A procedure for gifts and wills is in place and this prevents staff from becoming involved in residents’ interests. A policy is available in respect of the dealing with incidents of verbal and physical abuse although this is not applicable at this time. A policy is also available on restraint. The resident and her representative using this procedure have agreed the provision of bed rails to her bed. Recruitment procedures are outlined in the next section of this report yet there is reference to the use of the protection of vulnerable adults register in this process. Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 14 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 standard(s) No standards in this section were examined during this inspection. EVIDENCE: Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 Recruitment procedures are robust. Procedures protect and support residents. EVIDENCE: A total of two personnel files were examined. In both cases, a minimum of two references were on file. A criminal records check had been done for both individuals and this included evidence of a check against the protection of vulnerable adults register. Both files had proof of the individual’s identity. Application forms suggested that individuals had had experience in the care field in previous employment. Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 In the main health and safety systems protect residents and staff. There is no evidence that gas systems or hoists have been recently serviced. EVIDENCE: Manual training for staff is ongoing and records suggested that all have received training in manual handling, first aid, fire awareness and infection control. Fire awareness includes annual fire training and regular fire drills. All fire alarms are tested regularly as are emergency lighting systems. Fire extinguishers are checked annually. Radiator covers have been put installed into many areas as well as water temperatures regulated by thermostatic valves. Risk assessments relating to manual handling have been devised for each individual resident and general risk assessments for safe working have also been completed. Accidents are recorded when they occur and records maintained. Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 17 The gas soundness certificate available during the visit was not current and it is required that a current one is obtained. Servicing to hoists did not suggest that these had been regularly serviced. This is raised as a requirement in this report. Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 2 Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 19 NO Are there any outstanding requirements from the last inspection? 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 3 Regulation 14 Requirement Assessments completed by the home should be dated to evudence that prospective residetns have having their needs assessed prior to admission A current gas soundness certificate confirming that these systems have been checked must be produced Fixed and portable hoists must be serviced every six months under LOLER regulations Timescale for action 31 August 2005 2. 38 23 31 August 2005 31 August 2005 3. 38 23 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. Refer to Standard 8 12 Good Practice Recommendations Residents should have their weight monitored more regularly Documents outlining schedules for resident bathing should be worded in a less rigid manner Peacehaven F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Burlington House, South Wing, 2nd Floor 2nd Floor, Crosby Road North Waterloo, Liverpool L22 0LG 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 F53 F03 S5352 Peacehaven V241500 28.07.05 Stage 4.doc Version 1.40 Page 21 - 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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