Inspection on 19/04/05 for Peasholm Court

This inspection was carried out on 19th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 15/01/07

Peasholm Court 01/11/05

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 David Blackburn Unannounced 19 April 2005 09:30 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 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 Stationary 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Peasholm Court Address 99 Peasholm Court, Scarborough, North Yorkshire YO12 7NB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01723 362333 Mr James Bhagwutt 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 Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 02/11/2004 Brief Description of the Service: Peasholm Court is a large detached building situated in a residential are 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 Version 1.10 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 first to be undertaken in the inspection year April 2005 to March 2006. It was carried out over 5 hours including preparation time. It focused on a number of the key standards together with those subject to requirements or recommendations at the last inspection. An inspection of some of the premises, including two bedrooms, was undertaken. A number of records were also examined. Discussions were held with one of the home owners, the one member of staff on duty and the three residents. What the service does well: What has improved since the last inspection? What they could do better: Relatives, families and other people who visit the home should be asked for their views on the care and services provided by the staff. The owners should continue to produce those policies and procedures needed to ensure residents are well cared for. All fire doors must close properly to give people in the building reassurance that their safety will be promoted. Evidence must be provided that the gas supply and equipment in the home are safe to protect residents from any unnecessary risks. Peasholm Court Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Peasholm Court Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Peasholm Court Version 1.10 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 standard(s) 1 and 2. Information available from the home together with a good pre-admission assessment procedure provided residents and prospective residents with sufficient details on the care and services in the home to enable them to make a balanced judgement as to whether or not the home could meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide met current requirements. Both were revised last year. They were supported by a Residents’ Charter, the terms and conditions of residence and other general information about the home. The registered provider said consideration was being given to the formal publication of the Service User Guide. Pre-admission assessment forms and initial care plans had been completed by staff from the placing authority, some under a Care Programme Approach. The information on file was comprehensive and informative about each resident’s initial needs and wishes. The information provided the basis for the care plan and on-going meeting of needs within the home. Risk assessments were in place. Any restrictions or limitations were recorded. Peasholm Court Version 1.10 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 standard(s) 6 and 7. Residents can be confident their needs and choices are being met through the clear and consistent care planning system. Residents exercise their own daily choices that allow them to decide how to live their lives. EVIDENCE: All three residents’ files were examined. They all contained a care plan and risk assessment with clear reasons given for any imposed restrictions or limitations. Care plans had been signed by the individual resident. Residents had been offered copies of their plans. Care plans had been reviewed on a six monthly basis and had been signed by the manager and resident. Updated risk assessments had been similarly signed by both parties. The files also contained a daily record of events that were up-to-date, succinct, and relevant. Residents felt their needs were being met. “I’m happy and well looked after.” Residents said they were free to organise their own day. “ I’m free to come and go as I want.” “They don’t insist I do things to please them. I do them to please me.” While some restrictions were in place these would only be enforced where a resident placed himself or others at risk. The registered provider said a close but discreet supervision was kept on residents. Advice, guidance and suggestion were used rather than direction. Residents collected their own money and looked after their financial affairs. Peasholm Court Version 1.10 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 standard(s) 12, 13 and 15. Good contacts have been made with the local community enabling residents to have good and meaningful social interaction. Family contact is promoted giving residents the opportunity to go on home leave or welcome relatives into their home. EVIDENCE: None of the residents had paid or voluntary employment. All said they were “not interested.” “I’m too old now. It’s retirement not work that interests me.” Similarly none was interested in further education. “I’ve done all the schooling I’m doing.” The registered provider said attempts had been made in the past to encourage residents to seek employment but all had failed. All residents could leave the home unaided. They said they used the local shops, pubs and cafes. Public transport passed the door. The registered providers also used their own motor vehicle to provide outings. Residents said they had been out the previous weekend and had enjoyed fish and chips. All residents’ names were said to be on the local electoral roll. The minutes of recent Residents’ Meetings showed the planned outings for the coming month. Two residents said they had good family contact either by visits to them or through their (family) visits to the home. One resident had been to stay with his mother for a week. A second had members of his family visit him the previous week. “My brother visits every couple of weeks and my mother’s Peasholm Court Version 1.10 Page 11 sister came this weekend.” The third resident refused any family contact though the registered provider said he was aware of their address. Attempts to promote contact had failed. (He steadfastly refused to see any members of his family.) 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 standard(s) 20 and 21. Medication was well managed promoting the health of residents. Each resident’s wishes and choices on the care when ill and the arrangements to be made following death were recorded ensuring their needs were known. EVIDENCE: A medication policy including self-medication was seen. One resident takes medicines. He self-medicates. His medication was kept in a locked cupboard. He and the registered provider held keys. The resident said he was happy with this procedure. He stated that he collected his own prescription, obtained the relevant medicines and ensured they were placed in the cupboard. Staff observed him taking the medication to ensure the correct dosage at the correct time. The last risk assessment on his case file noted his continued ability to self-medicate in a proper and safe manner. Policies and procedures on the care of the dying and the arrangements to be made following death were seen. Each resident’s wishes on these aspects were recorded in their individual case files. They had been signed by the resident and the registered provider. Peasholm Court Version 1.10 Page 12 Peasholm Court Version 1.10 Page 13 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 standard(s) 22. Concerns and complaints were addressed properly. Each resident’s views were taken into account. EVIDENCE: A relevant and detailed complaints procedure was seen. This showed how to complain, verbally or in writing, to whom, timescales for response and the expected outcomes for the complainant. It made clear reference to the right to approach the regulatory authority at any time. A copy had been given to each resident. They had signed to say they had read and understood the procedures. “If I’m bothered about anything, I see them (the staff).” The minutes of the Residents Meetings mentioned the raising of any worries, concerns or complaints. None had been raised over the past few months. “Listen I’m a complainer. If I’m not happy I’ll let them know.” Peasholm Court Version 1.10 Page 14 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 standard(s) 24 and 30. Recent investment had improved some aspects of the home creating a comfortable and safe environment for those living there. EVIDENCE: The premises appeared to be in good structural condition and decorative order. All rooms were occupied on a single basis. Two of the three bedrooms were seen with permission of the occupants. Both had an en-suite facility. New carpets had been provided to the bedrooms and new vinyl covering to the ensuites. A new shower had been installed in one of the en-suites. “I’m very happy with the new shower and with the whole of my room.” Good quality furnishings were seen and found to be in serviceable condition. A planned programme of maintenance and renewal was examined. There are a number of communal rooms including one for those who wished to smoke. “We can only smoke in here.” Those parts of the premises seen were clean, tidy, warm and free from offensive odours. Appropriate arrangements were in place for the laundering of bedding, linen and personal clothing. Proper procedures were in place for the transfer of items from bedroom to laundry. The laundry was adjacent to the kitchen but a separate access was available eliminating the need to go through the kitchen. Peasholm Court Version 1.10 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 and 35. The small staff team had the skills, knowledge and experience to give residents the confidence that they would be offered a consistency of care and the proper meeting of their needs. EVIDENCE: The staff team comprised the registered providers and a relative. One other person is currently in the process of being appointed. The return of the enhanced disclosure from the Criminal Records Bureau was awaited before the appointment could be confirmed. All the present staff had a nursing qualification including two registered mental nurses (RMN) and one registered general nurse (RGN). All held current Nursing and Midwifery Council (NMC) registrations. Staff were well experienced in the care of the resident group and displayed the knowledge and skills required to meet residents’ needs and ensure consistency of care. Residents were complimentary about the staff team. “They’re a good bunch.” “They look after me OK. I’ve no grumbles about them.” “He’s an absolute gentleman (staff member).” The training needs of staff had been analysed and a plan to meet those needs drawn up. The registered provider said training had been undertaken on a number of subjects including fire safety, health and safety and manual handling. Certificates were seen. Other staff were programmed to undertake this training the following month. Peasholm Court Version 1.10 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 40 and 42. Systems and procedures were being introduced to ensure residents were cared for in an appropriate and consistent manner in keeping with their needs and choices. Proper attention was being given to matters of health and safety to promote and maintain a safe and secure environment in which residents could live. EVIDENCE: A questionnaire had been devised and piloted. It was to be given to all residents. It was recommended that a similar questionnaire be distributed among relatives, visiting professionals and other stakeholders. The registered provider said feedback was also gained through one-to-one discussions with residents and through the Residents Meeting. Policies and procedures were being reviewed and revised as necessary, together with the introduction of new ones, in line with those listed as service relevant in Appendix 2 to the National Minimum Standards (Younger Adults 2nd edition). Peasholm Court Version 1.10 Page 17 Attention was being given to the promotion and maintenance of the building to provide a safe environment for the residents, visitors and staff. A number of satisfactory safety reports and certificates were seen relating to the premises. It was noted that one fire door did not close effectively. The registered provider said the gas installations and supply had been checked and serviced the previous week. A diary note was seen to this effect. No safety certificate however had yet been issued. Peasholm Court Version 1.10 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x x Standard No 31 32 33 34 35 36 Score x 3 x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 Score x x 3 Standard No 37 38 39 40 41 42 43 Score x x 2 2 x 1 x Page 19 Peasholm Court Version 1.10 21 3 Peasholm Court Version 1.10 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. 2. Standard 42 42 Regulation 13(4) and 23 (4) 13(4) Requirement All fire doors must operate in an effective and efficient manner. Evidence must be provided to show that the gas installations and supply have been serviced and are safe. Timescale for action 30/04/05 30/04/05 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 39 40 Good Practice Recommendations The use of the questionnaire to ascertain the views of residents should be extended to seek similar views from relatives, visiting professionals and other stakeholders. The registered providers should continue to formulate and implement those policies and procedures seen as service specific and detailed in Appendix 2 to the National Minimum Standards for Homes for Adults (2nd edition) Peasholm Court Version 1.10 Page 21 Commission for Social Care Inspection 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 © 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 Peasholm Court Version 1.10 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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