CARE HOME ADULTS 18-65
Peasholm Court 99 Peasholm Drive Scarborough North Yorkshire YO12 7NB Lead Inspector
David Blackburn Unannounced Inspection 1st November 2005 09:15 Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 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 Peasholm Court DS0000007679.V261167.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 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. Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Peasholm Court Address 99 Peasholm Drive Scarborough North Yorkshire YO12 7NB 01723 362333 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) Mr James Bhagwutt Seegoolam Anne Marie Seegoolam Mr James Bhagwutt Seegoolam Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th April 2005 Brief Description of the Service: Peasholm Court is a large detached building situated in a residential area of the town. Within easy walking distance of local facilities and amenities it also provides good transport links to neighbouring towns and villages. The building, originally a hotel, was converted to a care home for 10 people some years ago. In 1991 it was registered for three people. The premises occupy three floors. The upper floor is used by the registered providers and their family. The middle floor has residents bedroom accommodation while the ground floor houses the communal areas. The home provides accommodation and services for three people, under the age of 65, who have had or who are experiencing mental health problems. Each person has a single room. Two bedrooms have en-suite facilities while the third has adjacent toilet and bathroom. There is ample communal space. The staff seek to provide personal care where required, together with help, advice and guidance on daily living skills and activities, a catering service, a laundry service and domestic and cleaning services. All these are offered in conjunction with input from residents. All residents can leave the premises unaided and take advantage of the many attractions in the town. They are registered with a local medical practitioner who will make arrangements for the provision of more specialised health services where needed. Residents have direct access to community psychiatric nursing services. Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection upon which this report is based was the second to be undertaken in the inspection year April 2005 to March 2006. It was carried out over four hours including preparation time. It focused on those key standards not addressed at the first inspection together with those subject to requirements or recommendations. An inspection of some of the premises, including one bedroom, was undertaken. A number of records were also examined. Discussions were held with one of the registered providers, the one member of staff on duty and the three residents. A telephone conversation was also held with a visiting health care professional. What the service does well:
Residents could be assured their strengths, needs and how they would be met, were properly assessed and recorded prior to admission. Full risk assessments subject to regular review were available ensuring any identified risks could be minimised or eliminated to safeguard the welfare of the individual resident. Routines were at a minimum in the home giving residents the freedom of movement, choice and independence. One resident said “I’m free to come and go as I want.” Residents expressed their satisfaction with the overall catering service provided in the home. A resident said “The food here’s great. You’ll not find better anywhere.” Personal care and health care needs were well identified, recorded and met ensuring residents had the appropriate care at the required time. A resident commented that his overall health had improved since he had been at the home. In a telephone conversation with a visiting health care professional no concerns were raised about the overall care and services on offer. A number of positive comments were made about how the general health of each resident had been promoted and maintained. A good staff recruitment and selection policy was in place that clearly detailed the checks required. These procedures acted as a safeguard for the residents. The premises were generally well maintained with attention given to matters of health and safety ensuring residents lived in a safe environment. All residents made positive comments about their bedrooms, the facilities they enjoyed in their rooms and the comfortable communal areas. Peasholm Court DS0000007679.V261167.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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 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 Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Residents’ needs were properly assessed prior to admission ensuring they could be understood and met. EVIDENCE: There had been no new admissions since the inspection in April this year. The last admission was over three years ago. Scrutiny of the three case files showed an initial assessment had taken place identifying strengths and needs and detailing any known risk factors. Care plans devised by care managers of the placing authorities had also been provided. These formed the basis of the care plans used in the home. Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9. The overall safety and welfare of the residents were well promoted through good risk assessment procedures. EVIDENCE: Each of the three files examined contained a risk assessment. An original risk assessment had been produced prior to admission. These had been updated every six months over the past two years. The last review had taken place in December 2004. The registered provider said re-assessments would now be undertaken annually unless circumstances dictated an earlier review. They were comprehensive in nature and clearly detailed the areas of risk or concern, how they might be manifested and the actions to be taken to minimise or eliminate those risks. The residents had signed their own risk assessment. Residents said they were free to come and go as they wished. None felt any undue restrictions had been placed upon them. They were aware of their risk assessments and those situations that could pose a danger to their overall welfare.
Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17. Residents had the right to freedom of choice, movement and independence recognised in their daily lives. Residents were able to exercise control over their diet and what they ate. EVIDENCE: Routines were designed around the residents. While a number of rules were in place, for example restrictions on smoking, these were designed for the overall benefit and safety of residents and staff. Residents felt rules were few, understood why they were in place and generally accepted them. Occasionally they admitted that the rules might be broken. Restrictions on smoking were recorded in the terms and conditions of residence. Any similar restrictions with regard to alcohol or other substances were shown on the individual resident’s care plan. Residents confirmed they had a key to their bedrooms and to the front door. They said they had access to all parts of the house and to the gardens. One resident spoke about helping with domestic tasks including keeping their rooms tidy, assisting with laundry and doing some cooking.
Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 11 At the July Residents’ Meeting it was agreed residents would take responsibility for the menu planning. A copy of the menu for the current and future weeks was seen. This showed a good and varied menu with some attention given to aspects of healthy eating. Residents said they were happy with the menu and that it provided meals they liked and enjoyed. Three meals were provided each day together with a light supper. All meals had a cooked option available. Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19. Clear and comprehensive arrangements were in place to ensure residents’ physical and health care needs were properly met. EVIDENCE: The care plans detailed the personal care and health care needs of each resident. All residents could self-care though staff provided the appropriate advice, guidance and encouragement where needed. Residents said they did their own shopping for clothes and other personal items. None of the residents required any specialist equipment. All were able to use the facilities provided in the home without the need for any form of aid or adaptation. Each resident was registered with a local general medical practitioner and had a regular annual medical check-up. Health needs were recorded on the care plan together with any required interventions. The community psychiatric nurse had an input into the home and his visits were recorded. In a telephone discussion with a visiting health care professional positive comments were made about the care and services provided. The health care professional felt
Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 13 the staff at the home had done much to promote the overall health and welfare of the residents. A number of improvements had been noted and this was due in part to the hard work of the staff. One resident spoke of the continued improvements to his health since admission. He felt the care regime in the home had been of great benefit in assisting his recovery. Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. Residents were protected from harm and abuse through staff’s knowledge and understanding of Adult Protection issues. EVIDENCE: A policy on adult protection was available, “Recognising Abuse”. This was supported by a number of other policies related to the protection of vulnerable adults including a Residents’ Charter, whistle blowing and the complaints procedure. The registered providers had a copy of the multi-agency protocol on the protection of vulnerable adults. They were advised to obtain a copy of the revised protocol. In discussion staff were confident in the procedures to be followed should abuse be alleged or suspected. Residents confirmed they handled their own personal money and affairs. Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The standard of the environment is good providing residents with a homely place in which to live. EVIDENCE: The building remained in a good state of repair internally and externally. Some re-decoration had been carried out since the last inspection. A new central heating boiler was being installed and better control made over heating to specific areas of the building. The residents had single rooms, two with en-suite facilities and one with exclusive use of an adjacent bathroom. One bedroom was seen with the resident’s permission. The resident said he “was very happy with the room. It has everything I need. The staff see this as my space.” Those parts of the premises seen were clean, tidy and odour free. Good systems were in place for the laundering of bedding, linen, towels and personal clothing. Proper attention was given to matters of hygiene and infection control.
Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34. Residents were supported and protected from harm through the registered providers’ recruitment and selection policies and procedures. EVIDENCE: The staff team comprised the registered providers and one staff member. No other staff were employed and no appointments had been made for over six years. All three staff had a relevant nursing qualification and held current Nursing and Midwifery Council registrations. Job descriptions were available should it be decided to appoint further staff. A recruitment and selection policy and procedure was in place. This made clear reference to the need for a thorough and detailed examination of any person applying for employment including a specific note about the need to obtain written references and an enhanced disclosure from the Criminal Records Bureau. Enhanced disclosures were available for the registered providers and staff member. Residents were complimentary in their remarks about the registered providers and staff. A good rapport was noted between the two groups.
Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40 and 42. Attention to some safety issues was required to ensure residents continued to live in a safe and secure environment. EVIDENCE: There was no quality assurance or quality monitoring policy or procedure in place. One is required that effectively reviews and shows, where required, the improvements needed to be made to the care, services and facilities on offer in the home. An audit tool designed to seek feedback on the performance of the staff and home had been produced but did not appear to have been implemented. A written survey of residents had been carried out and their replies were seen. It was suggested that the scope of this survey be widened to include families, friends, visiting professionals and any other persons with an interest in the care and services provided in the home. Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 18 Policies and procedures relating to the home were available in the Policy Manual. The registered providers and staff were aware of their responsibilities with regard to the maintenance of a safe and secure environment. A full risk assessment and analysis had been carried out on the premises earlier this year. This identified each area, any associated risks, the measures needed to control, minimise or eliminate that risk and any further actions that needed to be taken. Adjustments had been made to some fire doors following the last inspection. However it was noted that other doors required adjustment. The registered providers must ensure that all fire doors operate in an effective and efficient manner at all times. At the last inspection the gas installation and supply were being examined. A safety certificate was required following that inspection. The engineer recommended that a new more efficient boiler system be installed together with better heating controls for specific areas of the house. Work on these matters was in progress. A safety certificate for the gas installation and supply must be provided once this work is completed. Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Peasholm Court Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score X X 1 3 X 1 X DS0000007679.V261167.R01.S.doc Version 5.0 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA39 Regulation 24 Requirement Timescale for action 31/01/06 2. 3 YA42 YA42 13(4) and 23(4) 13(4) A quality assurance and quality monitoring system must be introduced that effectively reviews the care, services and facilities provided in the home. All fire doors must be adjusted to 30/11/05 ensure they close effectively and efficiently. A safety certificate for the gas 30/11/05 installation and supply is required on completion of the present work to upgrade the system. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA23 YA39 Good Practice Recommendations The registered providers should obtain a copy of the revised multi-agency protocol on adult protection. A survey should be undertaken to seek the views of relatives, visiting professionals and other stakeholders on the overall performance of the home. Peasholm Court DS0000007679.V261167.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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