Inspection on 15/01/07 for Peasholm Court

This inspection was carried out on 15th January 2007.

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

Peasholm Court 01/11/05

Peasholm Court 19/04/05

Peasholm Court 02/11/04

Peasholm Court 21/04/04

Peasholm Court 03/12/03

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

CARE HOME ADULTS 18-65 Peasholm Court 99 Peasholm Drive Scarborough North Yorkshire YO12 7NB Lead Inspector Pauline O`Rourke Key Unannounced Inspection 15th January 2007 09:30 DS0000007679.V327190.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 DS0000007679.V327190.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. DS0000007679.V327190.R01.S.doc Version 5.2 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 DS0000007679.V327190.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1st November 2005 Brief Description of the Service: Peasholm Court is a family run care home registered to Mr and Mrs Seegoolam to provide personal care and accommodation to a maximum of 3 younger adults with mental health problems. Mr and Mrs Seegoolam are the registered providers and Mr Seegoolam is the registered manager. The home is a large detached building that is situated in a residential area of Scarborough. Local community amenities and facilities are within walking distance and there is a good bus service in to town. Each of the bedrooms is for single accommodation, two of which have ensuite facilities while the third has an adjacent bathroom and toilet. These are situated on the first floor and are accessed via a staircase. There are wellmaintained garden areas and parking is available on the road. A Statement of Purpose and Service User Guide are available in the home on request. A copy of this report will be included when published. The fee level notified on 15th January 2007 is from £275 upwards depending on assessed needs and availability of funds. The fee includes personal care, accommodation all laundry with the exception of dry cleaning and transport costs when the service users go out as a group with the providers. DS0000007679.V327190.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered from the provider, service users and other professionals since the last visit to the home, which took place on 1st November 2005. A site visit to the home, which lasted 2 and half hours, was carried out on 15th January 2007. It focused on the key standards. 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 two service users. Feedback was also received from the service users and two professionals in response to questionnaires sent prior to the visit. What the service does well: What has improved since the last inspection? Since the last inspection a fire officer carried out a safety inspection and recommendations made at this time have been implemented to ensure the safety of the service users is not compromised. A gas safety certificate was requested at the last inspection and this has been provided to the Commission. DS0000007679.V327190.R01.S.doc Version 5.2 Page 6 A quality assurance survey was available at the last inspection but the providers extended the range of this survey to include professionals, relatives and visitors. Whilst they have sent these questionnaires out there has been no response from relatives. The provider continues to follow this up. 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. DS0000007679.V327190.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 DS0000007679.V327190.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user’s needs would be properly assessed prior to admission ensuring they could be understood and met. EVIDENCE: There have been no new admissions since the last key visit. There is a clear admissions policy in place and discussion with the management revealed it is thorough. Information is given to any prospective service user and/or their relatives or guardians. Any new service users have to be referred through the care management process and are subject to a multi disciplinary assessment. The manager is involved in this process and would be mindful of the current occupant of Peasholm Court in trying to maintain balance within the home. Any placement made is initially on a trial basis to ensure that the available staffing is suitable to meet their needs and the interactions with the other service users are appropriate. DS0000007679.V327190.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall safety and welfare of the service users were well promoted through good care planning and risk assessment procedures. EVIDENCE: The two service users have care plans and these were seen during the visit. They simply outline the level of support each person requires and there was evidence to show they are reviewed every six months. The plans include some risk assessments and discussions with the one member of staff on duty showed a good understanding of each service user. The service users spoken with were aware of their plans and said that they were involved in a meeting about the plan on a regular basis. One service user 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. DS0000007679.V327190.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have the right to freedom of choice, movement and independence recognised in their daily lives. Service users are able to exercise control over their diet and what they eat. EVIDENCE: The service users spoken with said that they could if they wanted to go out into the community and take part in the cultural and social life of the town. Although one service user said he was more than happy away from a lot of people and enjoyed his own space. The routines of the home are designed around the service users. Whilst 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. Service users felt there were few rules and understood DS0000007679.V327190.R01.S.doc Version 5.2 Page 11 why these 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. The service user care plans outlined family support and contact details whilst conducting the visit one service user was contacted by a relative and arrangements were made for a visit to take place outside the home. The service users had personal photographs displayed in their room of family and friends with whom they have some contact. Service users 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 service user spoke about helping with domestic tasks including keeping their rooms tidy, assisting with laundry and doing some cooking. The service users can choose on a daily basis what they want to eat although a regular menu is maintained. They also help with the grocery shopping and can influence their meals at that time The service users also said that the staff respect their privacy and always knock before entering their rooms. DS0000007679.V327190.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and comprehensive arrangements were in place to ensure service users physical and health care needs were properly met. EVIDENCE: The service user plans identified the level of support required pertinent to the individual concerned. The service users confirmed that the staff provide support as and when required whether that be guidance or physical help. Service user’s 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. DS0000007679.V327190.R01.S.doc Version 5.2 Page 13 The service users are registered with a local GP practice and evidence was available in their files to show that they had received appropriate dental and optical care. The staff at Peasholm Court have good working relationship with the local community mental health team and if necessary can call on them if they need support and assistance. One service user is on medication and he manages this himself and any follow up treatment necessary. The medication is kept in a locked cupboard in the kitchen and he can access his medication when necessary. He is responsible for all aspects of his medication and staff monitor this and record when he takes his medication in his daily records. Whilst staff are qualified nurses it is recommended they update their training in the safe handling of medicines. DS0000007679.V327190.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are aware of the complaints process and are protected from harm and abuse through the staff’s knowledge of the Adult Protection Policy. EVIDENCE: A complaints policy is in place and the service users spoken with, confirmed that if they were unhappy with anything they would be confident enough to tell the providers. They also said that they have people outside of the home, which would help them if they were unhappy. These contacts include community psychiatric nurses, volunteers at the local MIND support group and at least one of the service users has access to a care manager. There is a monthly meeting with the service users and providers and any general issues are discussed and minutes held. There is an Adult Protection Policy in place and this includes the local protocols in the event of suspected abuse taking place. In discussion staff were confident that the protocols would be followed appropriately if needed. The service users and their families handle their own finances. DS0000007679.V327190.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good providing residents with a homely place in which to live. EVIDENCE: The building remains in a good state of repair internally and externally. The service users have single rooms, two with en-suite facilities and one with exclusive use of an adjacent bathroom. One bedroom was seen with the service user’s permission. The service user said he “was very happy with the room. It has everything I need. The staff see this as my space.” The communal space was warm and comfortable. 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. DS0000007679.V327190.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user’s are supported and protected from harm through the registered providers’ recruitment and selection policies and procedures and through staff training. EVIDENCE: The staff team comprised the registered providers and two staff members both of who are related to the providers. No other staff are employed. Three of the staff have 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 DS0000007679.V327190.R01.S.doc Version 5.2 Page 17 Bureau. One member of staff has been employed since the last site visit and he was an immediate family member of the providers. The only documentation available for him was a current enhanced Criminal Records Bureau disclosure. The providers do not envisage employing anyone else within the home and have decided that further admissions will take the current staffing availability in to account. 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. Evidence was available to show that training has been accessed since the last visit with one proprietor undertaking infection control and resuscitation training and the staff member doing a course in adult protection. Further training Planned by the providers. DS0000007679.V327190.R01.S.doc Version 5.2 Page 18 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): 37, 39 and 42. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service users live in a well-managed and safe environment. EVIDENCE: An audit tool designed to seek feedback on the performance of the staff and home has been produced and had been implemented. This was complimented by a survey of families, friends and visiting professionals. The providers had received comments back form professionals but no family responses had been received. The information gathered through these questionnaires and through the monthly service user meetings is used to help develop the service. DS0000007679.V327190.R01.S.doc Version 5.2 Page 19 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 by the Fire officer, and these now provide effective protection in the event of a fire. A more efficient gas boiler has been installed and the central heating has been serviced a safety certificate was provided during the visit. DS0000007679.V327190.R01.S.doc Version 5.2 Page 20 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 X 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X DS0000007679.V327190.R01.S.doc Version 5.2 Page 21 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. Standard Regulation Requirement Timescale for action 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 YA20 Good Practice Recommendations It is recommended that the providers and staff complete a medication course that updates their skills and knowledge. 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