Inspection on 20/10/08 for Peacock Hay

This inspection was carried out on 20th October 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Peacock Hay 30/05/07

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOME ADULTS 18-65 Peacock Hay Peacock Hay Road Talke Stoke on Trent Staffordshire ST7 1UN Lead Inspector Wendy Jones Unannounced Inspection 20th October 2008 14:00 Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 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 Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Peacock Hay Address Peacock Hay Road Talke Stoke on Trent Staffordshire ST7 1UN 01782 786918 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) peacockhay1@tiscali.co.uk Voyage.com Milbury Care Services Ltd Ms Victoria Anne Vernon Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users will be ambulant but may have an additional physical disability 30 May 2007 Date of last inspection Brief Description of the Service: Peacock Hay is privately owned by Milbury Care Services and is registered to accommodate 7 adults with learning disabilities. People who use the service have varied abilities and may have communication difficulties, have autism and present with challenging behaviours. The home is situated on Peacock Hay road, off the main A500 at Talke, Staffordshire. The premises was formerly a guesthouse has extensive grounds, adequate parking and has been converted into a spacious care home. The property sits in an estimated ¾ acre of land. The immediate area around the home has been developed to provide suitable gardens and patio areas for the people living there. The main driveway is up a steep incline that leads to the large car park to the right of the home. Access to the front entrance is via a ramped pathway, which has handrails positioned on each side. People who may use the service and their supporters should approach the provider for the fee range and costs of the service. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a key inspection site visit of this service undertaken on 20 and 21 October 2008 and included feedback to the acting manager and operations manager. In total the visit took approximately 05:00 hours. The purpose of this visit was to assess the services performance against the National Minimum Standards and to establish if it provides positive outcomes for the people who live there. In addition to looking at areas of concern identified at a random visit to the service undertaken on 30 September 2008. The visit included checking that any requirements and recommendations of the previous inspection visit of 30 May 2007 have been acted upon. Since the last inspection we have carried out an Annual Service Review (ASR), this is a review of the service based upon information we receive, but does not include a visit to the service. We had been provided with an Annual Quality Assurance Assessment (AQAA) for the ASR and have used this information, which is the service’s own assessment of its performance to inform this report. We received completed surveys from relatives, staff, people who use the service and health professionals at the time of the ASR, and have sent out and received relatives surveys following this visit. During this visit we looked a range of records including care, health, staff and medication and spoke to staff, the operational manager, interim manager, a relative and people who use the service. What the service does well: What has improved since the last inspection? There has been a deterioration in the service delivered since the last inspection, with serious concerns being raised by relatives and health professionals. At this inspection, the organisation has been able to show us that they are taking action to address the concerns and improve the service. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who may use the service can be confident that their care needs are assessed and usually they are offered a place at the home only if their needs care be met. EVIDENCE: The service told us in the AQAA that, “We ensure that the choice of home is the most appropriate from the outset of the referral process. We employ senior care planners who identify and match potential service users with potential services. Initial assessments are then carried out that identify basic information and contact details as well as information on areas such as communication skills, specific health care needs, daily living skills etc. We talk to service users, other carers, care managers to try and get as much information as possible to make and accurate assessment of the ability of the service to meet the persons’ support needs, wishes and aspirations. If it is agreed that the placement should go ahead then we carry out more detailed assessment of need and draft a transition plan, detailing specifics of the individuals move to the home.” At the time of the ASR, some concerns were raised about the placement of a person in the home without proper provision made to ensure that they receive support from specialist health services. A health professional has also raised Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 9 some concerns about the breakdown in placement of another person under similar circumstances. We decided to carry out a random visit to look at these matters and following that visit of 30 September 2008 we wrote to the provider about our findings and said that we remain concerned about the admission and assessment procedures for the service. We asked for a review of the admission procedures to be undertaken to ensure that no one is admitted to the home unless their care or health needs can be properly met. During this visit we looked at a sample of assessment information and found that the records show very good assessment of need, involvement of family and relevant others and good opportunities to visit the home to test compatibility with other people living at the service. Relatives have told us that they received information about the service and had opportunities to visit the home. One said, “Until recently I have been satisfied with the service my relative has received.” A person living at the home said, “I came to look around the home and chose my bedroom before I came to live here.” Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that care records are in place based upon their know needs, but concerns about the implementation of them potentially puts them at risk. EVIDENCE: The service told us in the AQAA that, “Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. Support plans are produced with guidelines but are accessible and easy to understand and are written in plain language. There are comprehensive risk assessments taking into account the specialist needs and age of people who use the service, balanced with their aspirations for independence, choice and normal living.” We said in the ASR that, “The service operates a person centred approach to the delivery of care, each service user has support plans in place based upon the assessment of their needs, they are allocated a key worker and their plans Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 11 are reviewed at least monthly. Surveys indicate that this is an area where the service excels.” We looked at a sample of care and support records during this visit. We saw very detailed plans but cannot be sure that they are easily accessible or understood by the people who use the service. There is a huge amount of information in these records that we feel make them difficult to use and are concerned that they may become so cumbersome that staff will not use them properly. We also recommend that all staff receive training in the implementation of person centred planning. Daily records include monitoring of the plans, and monitoring of care and health needs. We observed information being recorded in a communication book that should be recorded in the daily care records of the individual. We spoke to the management team about this, as we are concerned that important information could be missed. A relative has told us, “Communication in the home is not great. I cannot always be sure information is passed on properly.” “My relative communicates with symbols and picture. When she moved into the house all staff were aware of this and communicated successfully. For some reason this means of communication is no longer used all the time.” “Since the operations manager has been involved I feel more confident that I am listened to.” Each person has a communication passport in place, this provides staff with the information they need to communicate effectively with, and understand people. There are people in the home who do not communicate verbally. We saw that risk assessments have been carried out and strategies are in place to ensure that people who use the service are not placed at unnecessary risk. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service have access to social, recreational and educational activities both in and out of the home. Although there have been concerns there have been times when this has been limited, which has impacted on their quality of life. EVIDENCE: The service told us in the AQAA that, “We ensure service users are respected and valued as individuals, by promoting independence, individual choice and freedom of movement. The service has a very strong ethos and focuses on involving service users in all areas of their life, actively promoting the rights of individuals to make informed decisions in all areas of their life. Service users are offered a choice of suitable menus, which meet their dietary requirements and cultural needs, and which respect individual preference.” Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 13 Relatives have said in surveys, “They take in to account my relatives needs and encourage her to participate and give her a very good quality of life.” “The home is endeavouring now to provide my relative with a very full and active life.” One relative is concerned that the records of activities are not accurate and said, “Activity plans are beautiful stories compared to the reality of what my relative does. It was said she didn’t like going swimming anymore, so why was she down to go swimming 3 mornings a week, not that she ever did.” These concerns have been passed to the provider to look into as part of a complaints investigation. Another relative said, “There have been staffing and gender issues that have been evident in denying my relative full access to activities e.g. Gym in the past.” We looked at the activity records for two people and saw a wide variety of activities available and there is evidence that activities are reviewed and changed based upon individual responses to them. But we also saw that the service has not always enabled people to attend the activities of their choice as regularly as their records say they should. We spoke to a member of staff who said, “We have had some staff difficulties recently, this has affected how often we can take people out.” During this visit we saw people, being taken out on activity sessions, out shopping and being taken to appointments and three people went out bowling and to the pub. People who remained in the home were observed sitting in the lounge with the TV on, there appeared at times to be little staff interaction. We discussed this with the interim manager for the service who confirmed that some new staff need to receive more training and guidance about effective interaction with people who use the service and intends to address this with individuals. We observed one person listening to music and then later playing with the table soccer game. We saw that one person had chosen to listen to music in her room and was receiving 1:1 support. We saw people who use the service have free access to the kitchen, although supervised and noted that pictures of cupboard contents are on cupboard doors for ease of recognition. We saw people help themselves to drinks with staff support and become involved with food preparation. Each person has their own menu plan; we saw that they usually say the same thing, although there are some differences. Food actually prepared is recorded separately. There are alternatives to the meal choices recorded. We spoke to a relative who was visiting the service; she stated she is satisfied with the range of activities provided. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. The service has provided care and support for people as determined from their care records and in conjunction with health professionals. But a failure to properly monitor health needs impacts on the quality of life of people who use the service. EVIDENCE: The service has told us in the AQAA that, “The service has separate policies on equal opportunities for service users, employees, and a policy on managing diversity, aiming to ensure that no one who has contact with the service receives less favourable treatment on the basis of sex, gender, re-assignment, marital status, age, race, colour, nationality, ethnicity, religion, disability or sexual orientation.” Both health professionals, who returned surveys, indicated that they had no concerns about the service in this respect. In our ASR of 23 May 2008 we wrote that there were positive comments in relatives’ feedback particularly about how the service meets the individual needs of people using the service and seeks assistance when required. But there were some concerns from a health professional about the placement of Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 15 people with complex needs from out of county, with what is reported to be a lack of consultation or discussion with local health services. It is suggested that this has caused problems with individuals not receiving the health care service they require. During the random inspection visit of the 30 September 2008 we were informed of some serious concerns relating to the health care needs of one person living at the home. The person had been admitted to hospital in an emergency and was seriously ill. In another example a health professional expressed concern about the experience and competence of staff when assisting a person to attend a health appointment. A complaint has been made to the provider about the alleged failure of the service to meet the healthcare needs of the person and a safeguarding strategy meeting has been held to determine if there is a continued risk to people who use the service because of these concerns. At the time of this visit, staff have received additional training from community health services and they are working with the team to ensure that staff have the knowledge they need to deliver appropriate care and to ensure that people’s health needs are better managed. There is a commitment from the provider to rectify any areas of concerns and to ensure that people who use the service receive the care and support they need, and additional management support has been bought into the home to support the staff team. We saw that people are supported to access health appointments and to receive specialist health care input. We saw that records are reviewed. Medication is stored appropriately and the medication records we have seen are properly maintained. One relative has raised concerns about staff competence in relation to medication administration and has complained about this issue to the provider. We are told that staff responsible for the administration of medication are trained to do so and also receive assessments of competence. We spoke to a member of staff who gave satisfactory responses to questions about medication. We recommend that the provider take action to ensure that all staff that administer medication are operating to good standards. None of the people who use the service self-administer medication. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure. But they must be sure that the service makes every effort to protect them from potential abuse or neglect. EVIDENCE: The service told us in the AQAA that, “All staff have Protection of Vulnerable Adults checks and Crimininal Record Bureau disclosures including workmen and contractors. Staff checks are kept on their personal files and should they have a conviction disclosure, but are still successful in employment then a comprehensive risk assesment is carried out. Complaints are managed effectively and responded to even if they are verbal or otherwise; they are logged in the complaints book and changes are made to ensure that situations reported do not occur again or are minimised were possible.” Two health professionals said, “The service always responds appropriately to any concerns we have.” An additional comment included, “The service has responded appropriately in the event of any concerns, however I do not feel that the senior managers of Voyage support the home when issues or problems arise.” A copy of a complaints procedure is displayed in the home and is included in a user-friendly format in the Service User Guide and Statement of Purpose. A complaints log is in place, which also includes evidence of how any issues are looked into and resolved. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 17 As a consequence of the concerns about the health care needs of one person and about the services ability to meet the needs of another person, a safeguarding meeting has been held. We have asked the provider to investigate the complaints they have received about these issues and report their findings and the outcome of that investigation to us. We have asked the provider to inform relatives that there have been concerns about the welfare of people who use the service and that social workers will carry out reviews of people who live at the service to ensure that they are receiving the support they require. A relative has said, “Since concerns have been raised Voyage have acted very swiftly to put matters right.” People who use the service said that they could go to staff if they have any concerns, one person said, “My key worker helps me with things.” A member of staff gave a satisfactory account of how she would deal with a complaint and how to recognise and suspected abuse. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent) This judgement has been made using available evidence including a visit to this service. The service provides an environment that is maintained to a good standard, reflects the age range of the people using the service, promotes independence and is safe. EVIDENCE: The interior of the service is a good standard. There are five communal rooms including a well-equipped sensory room, a dining room, an activity room that also provides some dining and lounge space, the main lounge and a spacious kitchen. A call system is fitted, for staff to use in an emergency or if they require assistance. All lounge and dining areas are furnished and decorated appropriately in a modern style that reflects the age range of the people using the service. The kitchen is of domestic design with sufficient storage space and work surfaces. People who use the service have free access to the kitchen. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 19 There are seven good-sized single bedrooms all have en suite bathroom or shower facilities. We did not see any of the bedrooms during this visit. The home does not have a lift to the first floor. There is a communal toilet on the ground floor, but no other communal bathing or toileting facilities in the home as each resident has en-suite bathing or showering facilities and toilets. There is a separate laundry facility. High-risk areas such as the laundry, COSHH and medication stores are locked, to prevent the risk of harm. There is a substantial garden with approximately 3/4 of an acre of land that is mainly grass. The people who use the service have a few pets that they take care of. One person said, “I enjoy looking after the rabbits and I’d like more animals.” One relative said, “I had an issue when I found my relative’s bathroom to be in dirty state and I cleaned it myself. I have reported this incident.” We found the home is clean and tidy throughout. Staff monitor and record hot water temperatures in bathrooms and en-suites on a daily basis. All hot water outlets have been fitted with thermostatic controls. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service should be confident that staff in the home are trained, skilled and in sufficient numbers to support them. But recent events and staffing shortages have impacted on people’s quality of life. EVIDENCE: The service told us in the AQAA that, “The result of the recruitment enables a diverse staff team to be in place which has a good balance of skills, interest, knowledge and experience and they demonstrated this through understanding of the particular needs of the service users.” Since the last key inspection visit there have been some staff changes and a recent loss of 6 permanent members of staff in a very short space of time. Agency staff have had to be used to cover the shortfall. A recruitment drive has resulted in the appointment of a number of new staff. This has had an unsettling affect and some relatives have expressed concerns. A relative has said, “We were very disappointed that we had not been informed of so many staff changes. In retrospect it impacted upon our relative’s mood Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 21 and behaviour.” Another said, “Peacock Hay has recently employed new staff I feel that they need time to get to know my sister.” Another felt that, “Staff are not trained properly, communication between shifts and management is really bad.” Staffing levels on the staff roster, show that the service usually provides 4-5 staff during the morning shift and the equivalent during the afternoon and evening, two waking night staff are provided at night. Additional staff are deployed at peak times to enable people who use the service to access activities. We noted that some older rosters show that staffing levels have not always been maintained at these levels, during the period when a number of staff left. At the time of the ASR we noted that the service did not have enough staff trained to National Vocational Qualification (NVQ) at level 2. We recommend that the service ensure that a minimum of 50 of staff receive the opportunity to enrol on this training. We have looked at the records of staff training and note that the majority of staff have attended mandatory training and there are dates in place for others to attend. We interviewed three staff during this visit; they confirmed that they had received a proper induction to the service, but one felt that it had been difficult because there were a number of new staff starting around the same time. One said, “There have been times when staffing levels have been poor, but we have recruited some new staff now and things are better.” We checked two staff recruitment records and saw that the records are not up to date. The operational manager has told us that the organisation does not allow staff to start work until all the pre employment checks have been carried out and has agreed to check that the records are properly maintained. We saw that Criminal Records checks have been carried out, files contained applications and written references have been sought. Staff said that they have been involved in staff meetings, but have not received a 1:1 supervision session with the manager of the service. One member of staff said, “I used to have regular supervision sessions, but I haven’t had one since June 2008, although I’ve asked for one.” We saw records of supervision, which show that the last supervision of staff took place In June 2008 also. We strongly recommend that the programme of staff supervision is recommenced. This will provide opportunity to monitor whether staff have the knowledge and ability to support the people using the service. The records also show that staff meetings were held monthly up until June 2008, but we couldn’t see a record of any since that time. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service must be confident that the service is properly managed to ensure that their needs can be safely and properly managed. EVIDENCE: The AQAA gives very good information about the service and how it is developing and there is a clear commitment to promoting equality. At the time of this visit we have been made aware the manager is currently not at work. Interim arrangements have been made for an acting manager to be at the home for two days per week to support the service, there is a fulltime deputy manager and the operational manager has been visiting very regularly. We have asked the provider to ensure that we are kept informed of any changes in the management of this service. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 23 One relative said, “Since my relative has been ill, I have lost all confidence in the management of this service, but am satisfied that my concerns are being looked into by Voyage and hope that things continue to improve.” “It is our opinion that there was a failure at management level to ensure that our relative’s health care needs were being monitored.” Issues around the high turnover of staff; staff supervision and concerns about the failure to properly monitor the health needs of people have been discussed in other sections of this report. We have asked to be kept informed of the outcome of complaints the service has received from relatives. We looked at records relating to fire safety and health and safety and saw that these are well maintained. Evidence in the Annual Quality Assurance Assessment, tells us that that all equipment in the home had been serviced regularly. Staff have attended mandatory training or that training is scheduled and have participated in Fire Drills. Appropriate policies and procedures are in place. The organisation is legally obliged to monitor the service and is expected to produce a monthly report. We asked to be provided with copies of these as the most recent were not available in the home, they have now been sent to us. We are aware that the organisation devises an action plan from these reports for the manager to work to. This provides evidence that the service is continually developing and trying to improve. It has been an unsettling time for the home, the people using the service, relatives and the staff, but we are assured that the organisation is addressing the concerns raised and is taking action to stabilise the staff and management teams. We will continue to monitor the service to make sure that these improvements continue. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 3 3 2 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 x 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 x 32 2 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 x LIFESTYLES Standard No Score 11 X 12 2 13 2 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 2 X 2 X 3 X X 2 x Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 25 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 YA19 Regulation 13 Requirement The provider must ensure that the health needs of people who use the service are met. To ensure that they are not placed at risk. Timescale for action 30/01/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA22 YA37 YA13 Good Practice Recommendations The provider should inform us of the outcome of the complaints investigation it is undertaking. The provider should ensure that we are kept informed of the management arrangements for the home. Continue to improve the opportunities people who use the service have, to be an active part of the community and to have meaningful community presence. Staff supervision should be undertaken regularly. 4. YA36 Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 26 5. 6. 7. 8. 9. YA32 YA20 YA33 YA33 YA3 A minimum of 50 of the staff team should be trained to NVQ level 2. The provider should ensure that staff competency assessment, in relation to medication is carried out regularly. The provider should ensure that all staff have the skills to communicate effectively with people who use the service. The provider should ensure that staff have the opportunity to meet regularly to discuss best practice. The provider should review pre admission and admission procedures fro the home to ensure that no one is admitted to the service unless their needs can be met. Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Peacock Hay DS0000068617.V372880.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!