Inspection on 08/02/06 for Peacehaven

This inspection was carried out on 8th February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Peacehaven 10/11/08

Peacehaven 16/11/06

Peacehaven 31/10/05

Peacehaven 11/01/05

Peacehaven 22/11/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Peacehaven 12 Kenilworth Road Leamington Spa Warwickshire CV32 5TL Lead Inspector Michelle O`Brien Unannounced Inspection 8th February 2006 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 DS0000004229.V283425.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 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.V283425.R01.S.doc Version 5.1 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 21 Category(ies) of Dementia (14), Old age, not falling within any registration, with number other category (21) of places Peacehaven DS0000004229.V283425.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. An amended statement of purpose must be produced to reflect the change in the number of registered places, category of registration and the location of the older persons places in the home. The seven bedrooms in the annexe on the first floor of the home are identified for only older people without a diagnosis of dementia. 31st October 2005 Date of last inspection Brief Description of the Service: Peacehaven is a large, period house, which is situated off the main road leading into Leamington Spa town centre and its amenities. The Bethany Guild owns the home and the Christadelphian 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.V283425.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the inspection year (April 2005 – March 2006) and was unannounced. The inspection took place over 5 hours commencing at 9.30am. The focus of this inspection was to assess the key standards not assessed during the previous inspection and review the home’s progress in meeting the requirements made. For a full overview of the home this report should be read along with the inspection report of 31st October 2005. On the day of inspection there were 21 residents being cared for in the home. The manager’s assessment was that there was an equal mix of residents with low, medium and high dependency need. The inspector spent time in the main communal lounge of the home and observed working practices and staff interaction with residents. General conversation was held with some residents here. 3 residents were visited in their rooms and their experience of the home and the service they receive was discussed. Documentation maintained in the home was examined and this included care files of residents, staff personnel files and training records, policies and procedures and records maintaining safe working practices. A trainee manager and senior member of the care staff were present during the inspection; the inspector would like to thank staff and residents for their co-operation and hospitality. What the service does well: What has improved since the last inspection? Peacehaven DS0000004229.V283425.R01.S.doc Version 5.1 Page 6 The procedures for the recruitment of staff have improved ensuring that all safeguards are accessed to offer protection to residents living in the home. 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.V283425.R01.S.doc Version 5.1 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.V283425.R01.S.doc Version 5.1 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): All key standards were met when assessed during the last inspection so have not been assessed during this inspection. EVIDENCE: Peacehaven DS0000004229.V283425.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8 and 9 were assessed. Residents’ care plans do not contain the necessary information to meet all of the identified needs of residents and are not consistently updated when there is a change in need. This puts residents at risk of not having all of there needs met. Regular review of the potential risks to residents’ health is necessary to protect them from harm. The systems for the management of medicines are not robust enough to ensure that residents are protected from potential harm. EVIDENCE: The inspector examined the care files of four residents. The home records residents’ care plans on computer and printed copies are kept in very well organised care files for each individual resident. Information is easy to find and care plans seen give clear direction to staff in how to meet residents’ needs. Peacehaven DS0000004229.V283425.R01.S.doc Version 5.1 Page 10 There is evidence of ongoing assessment and residents are invited to review and agree their care plan and sign for this. Risk assessment tools are used to monitor moving and handling, tissue viability, falls and nutrition. There was evidence of the good practice of crossreferencing the outcome of the risk assessment to care plans to demonstrate that the care file is a ‘working document’. The shortfall in the care planning process is that although the plans are reviewed and evaluated regularly on a monthly basis, there is little evidence of care plans being written for new needs that occur between the reviews. Residents are weighed each month and any weight loss is identified and action taken. Residents are enabled to access their GP, optical and dental services and the community nursing service visit when required. It is of concern that although four residents were identified to have pressure sores, there were no care plans to give direction about pressure relief to prevent further deterioration or tissue damage. The home needs to implement preventative care plans for residents at risk of developing pressure sores as well as care plans prescribing the care needed for those residents with existing pressure sores. The systems for the management of residents’ medication were examined. Medicines are stored securely in a small downstairs office. The senior carer on duty holds the medicine keys and a spare set is held by the manager. The home uses a monitored dosage system (MDS) with medication being dispensed every 28 days. Medicines are administered by senior care staff. Staff training in the safe administration of medicines is through distance learning with a local college. The following concerns were raised in relation to medicine safety: The temperature of the fridge for storage of medication exceeds the recommended temperature. The receipt, balance and administration of controlled drugs are recorded inaccurately in the controlled drugs register. There is no method of auditing the number of tablets held for residents in the home, particularly ‘as required’ medication such as analgesics that are not included in the 28 day dispensing cycle of medication but are ‘carried forward’ to the next month. The home has no homely remedy policy and was administering ‘over the Peacehaven DS0000004229.V283425.R01.S.doc Version 5.1 Page 11 counter’ cough medicine and paracetamol to residents without prescription or homely remedy policy. The home has no method of auditing staff practice in the safe administration of medicine to residents. There is no recorded assessment or review of residents’ capacity to self medicate. Peacehaven DS0000004229.V283425.R01.S.doc Version 5.1 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): Standard 14 was assessed. Residents are encouraged and enabled by staff to exercise control over their lives resulting in increased self-esteem and quality of life. EVIDENCE: Residents spoken to confirmed that they had a choice in how they spent their day; for example, what time they get up and go to bed or whether they spend time in their rooms or in the communal areas. Residents are involved in agreeing their care plans and their signatures on their care plans evidence this. Residents were observed to be at ease when asking for assistance from staff. Some of the residents continue to enjoy the interests they pursued before coming to live in the home with the support of staff and their families, such as participation in music groups and attending religious services. The home manager makes information about advocacy services available to residents. Peacehaven DS0000004229.V283425.R01.S.doc Version 5.1 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 the following standard(s): Standard 18 was assessed. The service has systems in place to protect residents from the risk of abuse, increasing their feeling of safety and their quality of life in the home. EVIDENCE: The policy for responding to allegations of abuse was revised in 2005 and is available with clear guidance for staff to follow. A copy of the Local Authority Guidelines for dealing with allegations of abuse is also available. Training records showed that most staff had attended recent abuse awareness training sessions. Peacehaven DS0000004229.V283425.R01.S.doc Version 5.1 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 the following standard(s): Standard 19 was assessed. The home is warm and clean with no offensive odours and provides safe and comfortable surroundings for service users to live in. EVIDENCE: On entering the home the inspector found it warm, bright and welcoming. The main communal areas and three of the bedrooms were seen. The home is traditionally decorated. There are two lounges; one quiet area and the main lounge which adjoins the dining area. Large windows allow for lots of natural light. Several residents used the main lounge; the seating provided is comfortable, appropriate and in good condition. There was evidence of residents’ activities such as art work on the walls, games and puzzles, and some of their personal belongings. Bedrooms viewed were clean, tidy and residents had brought in some of their personal belongings such as photographs, soft furnishings and small items of furniture. The home was clean and had no unpleasant odours. Peacehaven DS0000004229.V283425.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 29 and 30 were assessed. Staff were observed to be sufficient in number to meet the needs of the residents in the home and competent to do their job. This results in appropriate care being given and an increase in the quality of life for residents. The recruitment practices in the home are sufficient to ensure the support and protection of the residents. EVIDENCE: The inspector was informed that the usual staffing complement for the home is: 8am – 2pm 2pm – 10pm 10pm – 8am 1 senior carer and 4 care staff 1 senior carer and 3 care staff 2 care staff (awake throughout the night shift) These staffing levels were confirmed by examination of 4 weeks of duty rota in between 9th January and 5th February 2006. Peacehaven DS0000004229.V283425.R01.S.doc Version 5.1 Page 16 In addition, the manager of the home is supernumerary and has administrative support in the office for the day-to-day running of the service. There are sufficient catering, laundry and cleaning staff to ensure that care staff do not spend undue lengths of time in non-caring tasks. The home currently does not use agency staff. Staff spoken to on the day of inspection were professional and knowledgeable, their relationships with residents were observed to be good. Three staff personnel files were examined including two of the most recent employees 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. The outcomes of CRB checks are provided in the form of an email from the head office of Christadelphian Homes. These indicate that the outcome was satisfactory but give no indication as to what satisfactory means. The confirmation of CRB check should be held securely in each individual personnel file and not in a general file in the office as they may contain sensitive personal and confidential material. Training records examined show that training is undertaken by staff. Statutory training is up to date staff and include Fire, Health & Safety, Infection Control, Moving and Handling and Food Hygiene. Other training evidenced as attended by staff includes adult protection, Dementia, Safe Administration of Medication and First Aid. A training plan for 2006 has been made identifying staff members’ individual training needs. Peacehaven DS0000004229.V283425.R01.S.doc Version 5.1 Page 17 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 34, 35, 36, 37 and 38 were assessed. The procedure for managing residents’ personal monies needs to be reviewed so that residents can have access to their money on request. Although some staff have received supervision to ensure they are providing effective care this is not consistently planned and implemented for all staff which increases the risk of harm to residents. The policies and procedures for safe working practice in this home are ensuring that service user health, safety and welfare is being promoted and protected. EVIDENCE: The inspector was informed that residents’ personal monies held for safe keeping are kept in a locked cash box in the safe. The key to the box is held by certain members of staff and was not available in the home on the day of inspection. Consequently, the inspector was unable to check that the balance of personal monies kept for each resident was accurate. It is of concern that if Peacehaven DS0000004229.V283425.R01.S.doc Version 5.1 Page 18 the key to personal monies was not available then this restricts residents’ access to it. 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 home’s maintenance records and personnel files were organised and well maintained. The home has a Health and Safety Action plan and generic risk assessments are available for environmental hazards. Records were examined to establish safe working practices within the home: Resident aids (such as hoists) have been serviced in September 2005 The Periodic Fixed Electrical Installation Inspection was completed in January 2004. Records were not available to confirm whether the recommendations made for maintaining the installation have been completed. Portable Appliance testing of electrical equipment was last done in November 2005. The home has a legionella risk assessment and records of monthly temperature checks of water outlets were seen. The home’s emergency call system was serviced in October 2005 The lifts were inspected in January 2005 and the home has a service contract. Records of Fire safety checks were up to date. The last fire officer’s visit was made on 27th June 2005. Confirmation must be forwarded to the commission that the recommended work to replace self-closing devices has been completed. The health and safety of people in the home is promoted by a planned programme of statutory training for staff in moving and handling, fire safety, infection control and Health and Safety The gas equipment in the home was last serviced in December 2005 but a Landlord’s Gas safety Certificate was not available. A copy of this must be forwarded to the Commission. Peacehaven DS0000004229.V283425.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 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 2 2 3 3 Peacehaven DS0000004229.V283425.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 OP7 Regulation 15, 17 Requirement Timescale for action 31/03/06 2 OP8 3 OP9 4 OP35 5 OP36 The registered manager must ensure that care plans are written to reflect the current needs of residents. 15, 16, 17 The registered manager must Sch 3 ensure that accurate and appropriate records are maintained of the incidence of pressure sores, their treatment and outcome in residents’ individual care plans. 13 The registered manager must make arrangements for recording, handling and safe administration of medications received into the care home. The concerns identified in this report on the management and administration of medications must be addressed within a risk management framework. 16 The registered manager must ensure that the procedure for the safe keeping of residents’ personal monies is reviewed in order that residents have access to their money on request. 18 The registered person must ensure that the planned DS0000004229.V283425.R01.S.doc 31/03/06 30/04/06 30/04/06 31/05/06 Peacehaven Version 5.1 Page 21 6 OP38 13, 23 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. (Previous timescale of 31/12/05 not met) The registered person must 31/05/06 ensure that the issues identified in the ‘Management and Administration’ section of this report relating to safe working practices are addressed. 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.V283425.R01.S.doc Version 5.1 Page 22 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.V283425.R01.S.doc Version 5.1 Page 23 - 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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