Inspection on 31/10/05 for Peacehaven

This inspection was carried out on 31st October 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 10/11/08

Peacehaven 16/11/06

Peacehaven 08/02/06

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 Unannounced Inspection 31st October 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 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.V263219.R01.S.doc Version 5.0 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 Christine Furniss Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 2005 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 it’s amenities. The Bethany Guild owns the home and the Christadelphian ecclesia 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. Peacehaven is not registered to provide nursing care nor specialist dementia care. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of the year (April 2005 – March 2006) and was unannounced. The inspection took place over 6 ½ hours commencing at 9am. On the day of inspection there were 20 residents being accommodated in the home. The inspector had the opportunity to meet several of the residents and talk to two of them about their experience of the home. General conversation was held with other residents along with observation of working practices and staff interaction with residents. The inspector joined the residents in the dining area for their midday meal. Documentation maintained in the home was examined and this included care files of residents, staff personnel files and training records and policies and procedures. A good response to the commission’s comments card surveying the views of residents and their families was received before the inspection. The registered manager was present during the inspection and co-operated with the inspection process. The provider has recently applied to the commission to change the registration of the home in order to care for elderly people with dementia. What the service does well: What has improved since the last inspection? Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 6 All staff have attended dementia training, which is accredited by the Alzheimer’s Society. 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.V263219.R01.S.doc Version 5.0 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.V263219.R01.S.doc Version 5.0 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): Standards 1, 2, 3 and 4 were assessed. Prospective residents are provided with information to enable them to make an informed choice about where to live. Residents are provided with a statement of terms and conditions with the home to ensure they have information about their rights and responsibilities. Residents have their needs fully assessed before admission to the home to ensure that their needs can be met by the home. EVIDENCE: The Service User’s Guide and Statement of Purpose were revised in October 2005 and provide prospective residents and their families with information about the service and the rights and responsibilities of residents. The inspector was shown a sample contract of terms and conditions which residents sign when they are admitted to the home. Copies of the contracts are kept at the organisation’s head office. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 9 The head office of the organisation manages the waiting list of prospective residents. When a place in a home becomes available a manager from Christadelphian Care Homes is nominated to make the pre-admission assessment of the needs of the resident. The assessment form that is completed takes into consideration health, personal and social needs of prospective residents to ensure that their needs could be met by the home. A summary of the resident’s life experiences is included in ‘All about me’. All relevant information was found to be collected in the care files of three residents examined. Each resident’s care plan is developed using the information from the initial assessment. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 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 and 10 were assessed. The actions required to meet residents’ identified care needs are described in detail in the individual plans of care to ensure residents receive the care they need. Residents are treated with dignity and respect, which will result in increased self-esteem and well being. EVIDENCE: The files of three residents were examined and all contained care plans detailing the actions necessary to meet the needs identified during the assessment process. The care plans are held on a computer but a printed copy is also available for ease of access for care staff. Information was recorded sufficiently to enable care staff to deliver the care required. It was evident from discussion with staff that they refer to the care plans for direction in delivering care to residents. Risk assessments are completed for mobility, falls, nutrition and tissue viability. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 11 It was evident that care plans are reviewed and evaluated each month. There was evidence that residents are involved in agreeing their plan of care and are encourage to sign their care plans. The inspector met and spoke with several of the residents and positive comments were made about the home and the service received. Relatives of residents praised the manager and staff for the standard of care, commenting on how their relatives were happy to be living in the home and how they had improved since their admission. Staff were observed to recognise the varying cognitive abilities of residents when communicating with them and used calm words of encouragement to alleviate anxieties and prompt their memory. Staff were observed to anticipate the needs of more dependent residents who had poor insight to their conditions and assistance was offered and given discreetly. Staff knocked on residents’ bedroom doors before entering and addressed residents appropriately. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13 and 15 were assessed. Activities provide meaningful stimulation, which has a positive effect on the mental well being of residents. Residents are supported to maintain contact with family, friends and the local community to meet their social and spiritual needs. Meals are well presented, wholesome and provide residents with a nutritious and balanced diet. EVIDENCE: The home has an ‘open visiting’ policy and residents can receive visitors at any time. There are strong links with the Christadelphian ecclesia as the home is especially for people from this community. Part of the philosophy of care in the home is that residents will have ‘the company of those who share their faith, hopes and values’. The Christadelphian Hall is adjoins the home and residents can access it through an internal door. Services are transmitted from the hall to the quiet room in the home so that residents who are unable to attend the hall can participate in services. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 13 The service supports residents to continue to have links with the outside community and this is demonstrated by staff supporting a resident to attend a weekly music class, which he participated in before his admission to the home. Staff informed the inspector that the members of the music class were planning a performance in the home and the residents had been involved in selecting music for the performance. Flower arranging classes and coffee mornings are held in the adjoining hall for people from the community as well as being accessible to residents. There is evidence of lots of stimulating activity in the communal areas of the home such as craft work and games. Residents have the opportunity to participate in meaningful activities. The inspector observed one resident being supported to complete a crossword puzzle and an afternoon bible reading and discussion session with a group of residents. The inspector joined residents in the dining room for their two course midday meal. A choice of meal is available daily from the planned menu and is chosen by residents the previous day. The home provided copies of the weekly menu on the tables and menu’s are reviewed seasonally. Snacks and drinks are available for residents at any time. The meal was well presented, hot and tasty. Residents around the dining table all made positive comments about the food provided and it was evident from their conversation that their likes, dislikes and favourite dishes were considered when the cook planned the menus Staff were observed to provide discreet and unhurried assistance to those residents that required it during the meal. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 17 were assessed Residents and visitors can be confident that complaints received are listened to, taken seriously and are acted upon. Staff enable residents to access public services and participate in the civic process to maintain their place in society. EVIDENCE: The home has a complaints procedure that ensures that concerns or complaints from residents or visitors are listened to and acted upon. The procedure is contained in the service user’s guide and is accessible to residents and visitors. One resident spoken to said that if she had any concerns she knew she could ‘just mention it to a carer and it would get sorted out’. The inspector examined the home’s record of complaints and found that the home had not received any complaints. The commission has not received any complaints about this service. Advocacy is provided by an independent advocacy service and the welfare committee of the Christadelphian Care Homes’ organisation. The manager does not hold any power of attorney or appointeeship for residents. Residents are supported to access public services such as NHS and local libraries. The Christadelphian ecclesia do not participate in the civic process of voting in local and general elections but the manager informed the inspector that residents who chose to vote would be given the opportunity to attend the polling station or have a postal or proxy vote. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 26 were assessed. Residents are provided with safe, homely and comfortable surroundings to live in and enjoy and the practices used to manage the control of infection protect residents from potential harm. EVIDENCE: The service provides a cosy and homely environment in which residents were observed to be comfortable and ‘made themselves at home’. One of the care staff accompanied the inspector on a full tour of the home and most of the bedrooms were seen. The home was clean, bright, tidy and there were no unpleasant odours. All of the bedrooms were seen and these were found to be furnished and pleasantly decorated creating an environment where residents can feel comfortable. It was evident that residents had personalised their rooms with their own items such as photographs, soft furnishings or small pieces of furniture. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 16 The inspector visited the laundry room talked to laundry staff who explained their procedures, which confirmed that there are systems in place for the management of dirty laundry. Protective clothing such as plastic gloves and aprons were available and arrangements are in place for the disposal of waste. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 28 and 29 were assessed. Over 50 of staff have achieved an NVQ in care at level 2 or above ensuring residents are in safe hands at all times. The recruitment practices in the home are not sufficient to ensure the support and protection of the residents. EVIDENCE: 17 out of the 21 care staff employed have a National Vocational Qualification (NVQ) in Care at level 2 or above which, at 81 , is well above the minimum requirement for 50 of staff to be qualified. 7 of the care staff have NVQ level 3 in Care. Two personnel files were examined of the most recently employed staff and these were found to contain the necessary pre-employment checks such as references, Criminal Record Bureau (CRB) and Protection of Vulnerable Adult (POVA) to ensure the protection of residents. However, the home needs to ensure that CRB and POVA checks are applied for before new staff start working in the home. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 18 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, and 36 were assessed The home is managed by a dedicated and effective manager who is able to discharge her responsibilities fully to ensure residents receive consistent quality care. Residents are involved in quality surveys and their opinions and views are used to develop the running and direction of the care home. Although some staff have received supervision to ensure they are providing effective care this is not consistently planned and implemented for all staff. EVIDENCE: The registered manager has been in post since 2001 and is suitably qualified to manage the home. It was evident that the manager has been attending various training courses to update her knowledge, skills and competence to continue to manage the home effectively. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 19 The home is visited each month by a member of the organisation’s welfare committee who audit the quality of the service. Copies of the report they produce are sent to the commission regularly. The manager was able to show the inspector evidence of residents’ surveys ensuring their opportunity to have their say in how the home is run. The process of supervising care staff has begun but is still inconsistent and not in any regular pattern. Staff need to have formal supervision six times a year to ensure that their development needs are met and that residents are cared for by competent staff. The inspector discussed with the manager how this could be achieved by delegating some of the task of supervision to senior staff. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 20 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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X X X X X X 3 X 3 STAFFING4 Standard No Score 27 X 28 4 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X X Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 21 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 OP29 Regulation 19 Sch 2 Requirement Timescale for action 15/12/05 2 OP36 18 The registered person must ensure staff files contain evidence that appropriate checks have been completed through criminal record bureau checks and the vulnerable adults register prior to working in the home. The registered person must 31/12/05 ensure that the planned programme of formal supervision is implemented covering supervision of all staff, which also incorporates examining care practices, to ensure that they are consistent and safely delivered by all staff. Peacehaven DS0000004229.V263219.R01.S.doc Version 5.0 Page 22 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.V263219.R01.S.doc Version 5.0 Page 23 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.V263219.R01.S.doc Version 5.0 Page 24 - 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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