Inspection on 12/01/06 for Peacemills Care Home

This inspection was carried out on 12th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Peacemills Care Home 01/12/08

Peacemills Care Home 05/12/07

Peacemills Care Home 31/01/07

Peacemills Care Home 12/07/05

Peacemills Care Home 09/11/04

Peacemills Care Home 18/05/04

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

CARE HOMES FOR OLDER PEOPLE Peacemills Care Home Perry Road Sherwood Nottingham NG3 3AQ Lead Inspector Steve Keeling Unannounced Inspection 12th January 2006 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 Peacemills Care Home DS0000002298.V271764.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. Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Peacemills Care Home Address Perry Road Sherwood Nottingham NG3 3AQ 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) 0115 960 2539 0115 985 6616 Community Care Plus Ltd Mrs Yana Susan Whitehouse Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mrs Whitehouse must undertake courses facilitated by Notts Committee for the Protection of Vulnerable Adults by 31 October 2005. a) Understanding Adult Protection and Your Role. b) Investigating Officer and Interview Skills. c) Managing Complex Investigations. 12th July 2005 Date of last inspection Brief Description of the Service: Peacemills is a care home providing personal care and accommodation for 40 older people. The home is located on the outskirts of Sherwood, a residential district in Nottingham approximately 3 miles from the city centre. There are a small number of local community shops near to the home and Sherwood itself has many other amenities including shops, pubs and restaurants, and a community centre. The home was opened in 1991 and consists of a two-storey purpose built building. There are 36 single bedrooms (35 with en-suites) and two double bedrooms (with en-suites). There is a car park to the rear of the property and a small enclosed garden. It is owned by Community Care Plus Limited whose Managing Director is Brian Rosenburg. The Registered Manager is Yana Whitehouse. Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over a 4 hour period and involved one inspector. The main method of inspection was case note tracking, this is a method of selecting service users within the home and discussing with them their expectations and experiences of living within the home environment. The case tracking method also analyses the records of the service users to ascertain if the service users identified needs are being addressed appropriately within the care home setting and that their safety and well being is being maintained. On this occasion two residents notes were case tracked. At the time of the inspection a total of 38 residents were accommodated at the home. It was evident that the management and staff within the home are very committed to providing a high standard of care for the service users. The manager and staff within the unit were very helpful and cooperative thus ensuring that the inspection process progressed in a professional and efficient manner. What the service does well: Service users spoken with stated that they are happy living at Peacemills Care Home, it was apparent that staff at the home are committed to the provision of a homely environment and service users stated that staff at the home are very hard working. Care staff were observed to be courteous and interactive with service users. It was established that an appropriate level of training is provided at the home in an attempt to promote optimum safety for service users at the home. To further ensure that service users are safe within the home environment the manager could evidence appropriate maintenance schedules appertaining to equipment designed to aid mobility. Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 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 Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 The home does not provide intermediate care services. EVIDENCE: N/A Peacemills Care Home DS0000002298.V271764.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): 7. 9. 10. The case tracking procedure established that the care plans examined did not fully address the health needs of the service users and as such it could not be established that health needs were being fully met at the home. Facilities for the safe self-administration of medicines are available should it be required at the home. Service users spoken with stated that staff at the home maintains respect and dignity. EVIDENCE: The case tracking procedure revealed that care plans formulated at the home were ineffective in meeting the holistic needs of the service users. One case tracked service user had been assessed as “at risk of falls” but no care plan was evident to effectively address the risk. A care plan identified the need to encourage a service user to mobilise/stand every four hours to inhibit the formation of pressure ulcerations, the evaluation Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 11 of the care plan could not evidence that this requirement was being performed at the home. Care plans appertaining to the management of service users with confusion or cognitive impairment lacked specific details to inform care staff should the service users become agitated. One case tracked service users had been assessed as being “high risk” in relation to moving and handling. Once again the care plan appertaining to this identified risk factor was ineffective in identifying specific equipment needed to manage the service users condition effectively. As such a potential risk of injury for both service users and staff alike within the home was established. A service user with diet controlled diabetes did not have a care plan to address this complication and as such it could not be established if her diabetes was being managed effectively at the home. Care plans that were evident within the service users documentation did not have times scales for re-evaluations although it was evident that the care plans were being re-evaluated on a monthly basis. The home maintains daily progress documentation for all service users in which elements of care identified in care plans should be evaluated effectively. It was evident that the evaluation process was not effective. The daily evaluation of the care afforded to one case tracked service users was recorded as “had visitors today” or “ son brought her flowers” which is not an effective evaluation of the care plans. In addressing the aforementioned shortfalls the manger of the home will review the care planning and evaluation process at the home. At the time of the inspection two service users were responsible for the selfadministration of medicines. It was established that should a service user wish to be independent in the administration of medicines the manager in conjunction with members of the multidisciplinary team would perform a risk assessment, if the service user was deemed as being safe, the service user would be supported to self medicate. It was evident that service users are afforded appropriate privacy, dignity and respect within the home environment. Service users spoken with were very complimentary about the way staff spoke to them. It was evident that staff always knocked on the resident’s bedroom door before entering. Service user spoken with also stated that the staff respected their privacy and dignity when bathing or performing personal care and that all staff within the home are very friendly and attentive to thier needs. Peacemills Care Home DS0000002298.V271764.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): 13. 14. 15 Service users are able to maintain contact with family, friends, and representatives from the local community as they wish. Service users can exercise choice and control over their lives. Service users are provided with a wholesome, appealing and balanced diet. EVIDENCE: It was established that no restrictions are in place in relation to visiting times. All service user spoken with confirmed that the home operates an open policy in relation to visiting times and that all staff within the home are friendly and obliging to their friends and relatives. At the time of the inspection two service users were attending a pantomime within the city of Nottingham and it was established that the management at the home encourages service users to interact beyond the homes immediate environment if at all possible. The manager of the home has recently appointed an enthusiastic activities coordinator so as to provide a choice of stimulating activities. Currently the home provides activities such as bingo, cards, dominoes and quizzes. Service users also have the opportunity to shop within Sherwood town centre with the Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 13 support of cares or relatives thus further promoting social interactions beyond the immediate home environment. It was evident that the food provided at the home is wholesome, nutritionally appropriate and varied. It was evidenced that service users always have a choice of meals and that daily menus are displayed for service users perusal. The overall appearance of the dining room is pleasing all dining tables were clean and dressed appropriately. All service users spoken with were particularly complimentary in relation to the quality and quantity of food provided at the home. Peacemills Care Home DS0000002298.V271764.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): 16. 18. Service users feel confidant that any concerns or complaints will be listened to, taken seriously and acted upon by the manager and care staff at the home. Residents are protected by the policies and procedures at the home. EVIDENCE: The manager of the home ensures that the complaints procedure is on display at the entrance hall to the home together with advocacy services to allow service users and their family and friend the confidence to report any concerns appertaining to the care afforded to them at the home. At the time of the inspection no complaints were being investigated. All service users spoken with were confident that the manager and the care staff would always address any complaints in a sensitive and professional manner and the service users would not hesitate to discuss any concerns in relation to the care afforded to them within the home environment. The manager also utilises a quality audit tool in the form of a questionnaire to further promote the services at the home. Service users and relatives can fill out the questionnaire and forward them to the manager of the home so she can address any concerns that the questionnaires might highlight. Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 15 Service users within the home all stated that they felt safe and protected in the home. Staff spoken with are aware of the homes policies in relation to the protection of vulnerable adults and were aware of what actions would be required it they suspected abuse was happening within the home setting. Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 16 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): 19. 26. The home provides a safe comfortable environment for the service users although some areas within the home and some items of soft furniture are somewhat shabby and tired. EVIDENCE: The inspection process allowed for the partial examination of service users bedrooms and communal living areas. All areas within the home were clean, homely, smelt fresh although some areas within the home are somewhat shabby and tired, especially the downstairs communal bathroom areas. The homes owner with the aid of the manager are currently planning a partial refurbishment and upgrade to the home and soft furnishings, the schedule has already been formulated, it is planned that the refurbishment should commence in the near future. It was evident that residents had many personal possessions in their bedrooms, family pictures, small items of furniture, televisions, radios and Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 17 ornaments were evident thus promoting a homely, pleasant environment for the service users. At the previous inspection the areas of concern that were identified have been address by the manager of the home. The uneven paths and trip hazards in the garden area has been addressed effectively as the area now incorporates a raised bed so as to encourage service users to participate in gardening activities in the summer months. It is planned that grab rails are to be fitted throughout the corridors to aid service user mobility and promote service users safety although work has not started as yet. Staff are now aware of the principles of infection control and training is now available in relation to this element of care. It was evident that all staff within the home were carrying alcohol hand wash to inhibit the bacterial colonisation of hands and it was also established that gloves and aprons are available at the home to further inhibit bacterial cross infection. It was established that a substantial sum of money will be made available to address the aforementioned concerns and the Commission for Social Care Inspection will require the registered provided to forward an action plan which addresses the issues. The Commission will be monitoring the progress of the refurbishment at the next inspection. Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 18 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): 27. 30. At the time of the inspection 38 service users were in residency at the home. Given that only 3 care staff are employed throughout the afternoon and night periods it is the inspectors opinion that the current staffing levels are insufficient to meet the needs of the service users. The manager and her deputy manager stated that care staff within the home received appropriate levels of training in 2005, although the training opportunities could not be fully evidenced at the time of the inspection. EVIDENCE: Staff employed at the home is not sufficient to meet the needs of the 38 service users accommodated at the home. On the morning of the inspection one senior carer and three carers were on duty. Throughout the afternoon period, one senior carer and two carers and were on duty and one senior carer with two carers covered the night period. The home does not employ any qualified nurses, as the home does not provide nursing services. Service users spoken with stated that the care staff are excellent but often “run off their feet”. Staff spoken with also believed that an additional member of staff would greatly enhance the provision of care afforded to the service users at the home. The manager stated that appropriate training opportunities are available to care staff employed at the home in an attempt to ensure quality care is Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 19 provided for the service users. The records appertaining to the training opportunities provided at the home were in the process of being reformatted by the deputy manager of the home. Statutory training courses, together with additional training courses attended by care staff at the home could not be evidenced fully due to the transitional period, as such the Commission for Social Care Inspection will required further evidence in relation to the training courses planned for the forthcoming year and evidence of the statutory training provided at the home in 2005. Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 20 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): 33. 35. 38. Service users are protected from financial abuse and their financial interests are safeguarded. The health and safety of service users is promoted at the home through a ongoing comprehensive maintenance programme. EVIDENCE: At the time of the inspection it was evidenced that the service users monies are effectively managed. Some service users are financially independent and lockable facilities are available in all service users rooms to ensure personal finances are secure and safe. Service users can also have their “spending money” managed at the home. It was established that a clear record of monitory transactions could be evidenced. All monies are securely stored, in individual plastic folders and Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 21 stored within a secure environment. Receipts are evident for all transactions performed, and a clear financial audit trail was evident thus protecting the service users from financial abuse. The manager of the home stated that a maintenance technician is employed for 28 hour per week. The role of the technician is to perform routine maintenance within the home environment together with safety checks. It was evidenced that the technician performed hot water outlet checks on a monthly basis together with staff call system checks, automatic door releases checks and emergency lighting and fire drills. At the time of the inspection the records appertaining to the control of Legionella contamination was not available and as such the Commission for Social Care Inspection will require evidence that precautions are in place to inhibit Legionella contamination. It was evidenced that outside contractors performs appropriate maintenance on all equipment designed of aid mobility such as wheelchairs, hoists and specialist baths. In attempting to run the home in the best interests of the service users the manager has attempted initiate a service user forum within the home so that issues relating to the care provided to service users can be openly discussed thus identifying and addressing any concerns. Unfortunately, due to the lack of interest from the service users the consultation process was abandoned. The manager of the unit relies on the service users questionnaires to gain an insight into the service users needs together with the one to one interventions performed by the activities coordinator and care staff at the home. Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 22 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 23 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. 1 Standard 7 Regulation 15 (1) Requirement The registered person shall ensure after consultation with the service user, or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met The registered person shall keep the service users plan under review The registered person shall ensure that the premises to be used as a care home are of sound construction and kept in a good state of repair externally and internally. The registered person shall ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of the service users. The registered person shall ensure that the persons employed by the registered person to work at a care home DS0000002298.V271764.R01.S.doc Timescale for action 31/01/06 2 3 7 19 and 26 15 (2) (b) 23 (2) 31/01/06 31/01/06 4 27 18 (1) 31/01/06 5 30 18 (1) (C) 31/01/06 Peacemills Care Home Version 5.0 Page 24 6 38 13 (3) receive training appropriate to the work they are to perform. The registered person shall ensure that arrangements to prevent infection, toxic conditions and the spread of infection at the care home. 31/01/06 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 Refer to Standard 38 Good Practice Recommendations The manager should have access to all documentation in relation to the maintenance schedule performed within the home. Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Peacemills Care Home DS0000002298.V271764.R01.S.doc Version 5.0 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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