Inspection on 15/03/07 for Peasmarsh Place

This inspection was carried out on 15th March 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Peasmarsh Place 26/02/09

Peasmarsh Place 09/02/06

Peasmarsh Place 06/10/05

Peasmarsh Place 02/02/05

Peasmarsh Place 20/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Peasmarsh Place Church Lane Peasmarsh East Sussex TN31 6XE Lead Inspector Caroline Johnson Key Unannounced Inspection 15th March 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Peasmarsh Place DS0000021186.V322318.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Peasmarsh Place Address Church Lane Peasmarsh East Sussex TN31 6XE 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) 01797 230555 clairebradley@peasmarshplace.co.uk Peasmarsh Place (Country Care) Limited Mrs Claire Angela Bradley Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users should be older people aged sixty five (65) years and over on admission. A maximum number of twenty four (24) service users should be accommodated. 9th February 2006 Date of last inspection Brief Description of the Service: Peasmarsh Place is a former shooting lodge set in five acres of grounds. Service users accommodation is provided on two floors. A shaft lift is fitted to provide level access to most areas. All private rooms and communal areas have extensive views across the estate and gardens. The fees for the home as of March 2007 range from £520 to £680 per week. Additional charges are made for hairdressing, chiropody, newspapers and magazines. The home ensures that copies of the inspection report are made available upon request and there is always a copy available in the home to refer to. Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process a site visit was undertaken on 15 March 2007 and the visit lasted from 09.45am until 4.15pm. During the visit there was an opportunity to meet with four residents and with the relative of one of the residents. Time was also spent with the manager, the deputy manager and with two members of care staff. A wide range of documentation was seen and these included three care plans and pre admission documentation for one resident. In addition records held relating to staff recruitment and training, menus, complaints, health and safety, residents meetings and staff meetings were all examined. A full tour of the building was not undertaken but all communal areas and at least five bedrooms were seen during the inspection. Following the inspection three relatives of residents were contacted to seek their views on the quality of the care provided in the home. Comments included ‘can’t fault the care’, ‘the care is very good, its 101 and I’m really pleased’ and ‘its excellent’. One relative stated that they were fully involved in the review of their relatives’ care plan and that the staff came up with some new ideas to try. She wasn’t sure if the new ideas had been implemented yet. One of the relatives spoken with stated that they had a few matters that they wanted to raise with the manager. What the service does well: What has improved since the last inspection? The arrangements for the management of the medication in the home have changed and the home is to be commended for the progress made in this area. A new format for care planning has also been introduced and considerable progress has been made to update all documentation. As part of this process Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 6 a new form has been introduced identifying what care staff need to know about each resident. Where possible residents will be encouraged to complete their own form but assistance can and is provided to complete the form. The form is an excellent tool for staff to assist them in meeting the needs of the residents. At the time of inspection the ground floor was being rewired. Since the last inspection the shutters on the windows have all been repainted and new ramps have been fitted to allow better access to the home. The homes practice is to redecorate bedrooms as they become vacant and this ensures there is a continual programme of redecoration in place. All staff now receive regular supervision and staff spoken with stated that they find this very useful. Each staff member now has a personal development plan. The home’s policy and procedure manual has been updated, some new policies have been introduced and all policies are now specific to Peasmarsh Place. All of the staff team have attended a two-day course on professional boundaries and code of conduct. When staff sickness occurs the home now has the ability to use either bank or agency staff. This means that staffing levels never fall below minimum staff levels. A Legionella assessment has been carried out and safe measures to prevent an occurrence have been implemented. 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. Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. 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. Information received, as part of the assessment process must be more detailed and be available to inform care planning. EVIDENCE: The statement of purpose seen during the inspection was detailed but did not include details of the Responsible Individual and also referred to two deputies rather than one, as is the case. The manager was confident that the statement had been updated on the computer and agreed to send an updated copy to the Commission. Pre admission documentation was seen in relation to one resident. Limited information was recorded on the assessment form. The manager advised that as part of the assessment process the prospective resident and some family members visited the home and a partial assessment was carried out. The Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 9 assessment following this visit was seen and as stated limited information was provided on the assessment form. However, following this visit the manager then went to visit the resident in their own home. She advised that she had carried out a more thorough assessment at the resident’s own home but the details could not be located. The home does not currently send out a letter following assessment to confirm that having regard to the assessment they can or cannot meet the identified needs. Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. Overall the quality of care planning seen was good and the information provided ensures that residents’ needs can be appropriately met. The home is to be commended for the progress made in the management of medication. EVIDENCE: Three care plans were examined on this occasion. The home have reorganised the format for care planning and as part of this process they have introduced a new form called ‘what you need to know about me’. The form provides a range of information about each of the residents’ wishes in relation to how they wish to spend their day, for example, what time they would like to get up at and go to bed at. In relation to one care plan, it was noted that the resident had completed their own form. Other residents had given staff the information to complete the form. Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 11 Care plans seen included very detailed information about the abilities and needs of the residents. Where needs were identified the action required by staff was detailed and where appropriate risk assessments were carried out. The one exception noted to this was in relation to one resident who has food liquidised and is fed. The care plan mentions to feed slowly but there was no risk assessment in place. Daily records are kept detailing information about personal care given to residents. There is less emphasis on how emotional needs are met or on progress with individual residents’ objectives. Staff spoken with during the inspection were able to describe the main needs of the residents that they are keyworker to. In relation to the management of one resident’s needs, it was noted that the home keeps a record of the action that they take and staff call on a district nurse when they need support to continue to manage a particular aspect of the resident’s care. It was not clear from the record keeping how long they should leave it before administering ‘as required’ medication and how long it should then be before calling the district nurse. It should be noted that in practice this has not caused any problems to date. Residents are supported to attend a wide range of healthcare appointments as necessary to meet their needs. Since the last inspection the home has totally reorganised the way in which they manage medication in the home. There is a detailed generic policy and procedure in place, which has also been adapted to make sure that it, is applicable to the home. It was noted that the policy states that the drug trolley must be kept locked to the wall when not in use and the medication room should also be locked. The medication room was locked but the chain was not on the trolley or attached to the wall. The manager advised that they have the chain in the office and it will be refitted. There were detailed records in place showing that it is possible to do an audit trail of medication from the time it is received into the home. A returns book is kept and there is also a homely remedies procedure in place. A small number of residents selfadminister their own medication and there is a risk assessment in place to determine any perceived risks associated. All staff have received training on the new medication system. Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. A good range of activities are offered to residents and the home is proactive in arranging new activities that offer greater stimulation and will enable residents to independently maintain contact with family members living abroad. The improvements made in relation to the catering arrangements mean that residents can choose alternatives to set meals and they can give regular feedback to the cook about the food served in the home. EVIDENCE: Activities include hairdressing, poetry reading, scrabble, craft afternoons, music and health, outings to places of interest, flower arranging and shopping at Jempsons, the local store. A group of residents hold a bridge party on a daily basis and they regularly invite their friends to join them. One resident stated that they love knitting and tapestry, others stated that they enjoy reading and watching the television. One resident continues to drive their Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 13 own car and goes shopping and to church independently. They also enjoy gardening. Staff advised that in relation to meeting residents’ religious needs, arrangements are made for vicars/priests to visit. This was evident in care plans. One of the residents recently celebrated their 100th birthday. Relatives organised a champagne toast and the resident’s family and friends, residents and staff all attended. The manager advised that contact with some of the relatives of the residents is often maintained via e-mail so the home are now looking to purchase a computer for use by residents. The company is also looking to purchase a car that will be shared with the sister home in Northiam. There is a four-week menu in place that is changed seasonally. The planned menu is distributed to residents one week in advance with an options card. There is also a comments section so that residents can say what they thought of each meal served. A small number of residents provide comments on a regular basis and comments vary but overall they are positive. Alternatives available to the main meal are stated and there are also a range of alternatives to the supper menu. Records show that residents choose alternatives to the set meals. The manager advised that they now have regular theme days. On the day of inspection Italian food was served. Two of the residents spoken with stated that the food served was lovely and one resident said they were not keen on Italian food but generally enjoy the food served. Overall residents spoken with stated that the food provided is very good. A relative stated that whenever they have visited the food served has been plentiful and their relative has no complaints. Each of the residents has their own table in the dining room. The manager stated that this is down to choice. The home have tried moving tables before but it was reported that residents have fixed ideas about how the seating arrangements in the dining room. One resident spoken with stated that mealtimes are very quiet and no one speaks. This resident suggested at a resident meeting that some background music be played, but the other residents did not take this up. Two relatives spoken with also stated that their relatives had talked to them about the quietness at mealtimes. The manager advised that they have tried on occasions to play some background music and they will continue to review opinions on mealtime arrangements. Sherry is served in the drawing room prior to the main meal and this is an opportunity for residents to meet and socialise. Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. Procedures in place enable residents to raise any concerns they might have about the care they receive. The home deals with complaints appropriately but record keeping in relation to the investigation process should be more detailed. EVIDENCE: There were two complaints recorded at the time of inspection. One was very recent and was still ongoing. Records showed that the second complaint had been completed within 28 days and a letter regarding the outcome was sent to the complainant. Records did not show the details of the investigation and there were some areas highlighted in the complaint letter that had not been referred to in the home’s response to the complainant. The Responsible Individual confirmed prior to the completion of this report that the home has amended their procedures and record keeping is now more detailed. One of the residents spoken with stated that they did not have any complaints but if they did, they know the procedure to be followed to raise concerns. The home has a detailed adult protection procedure in place. The manager advised that all staff receive training on the subject and as a follow on from Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 15 this staff attend a professional boundaries and code of conduct course. A staff member spoken with stated that this course ‘was very good’. Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. 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. The quality of decoration is very good, the gardens are extensive and well kept and the views from the bedrooms are impressive ensuring that residents have a very comfortable, and homely environment. EVIDENCE: Not all bedrooms were seen on this occasion but those seen were well decorated and had been personalised by the residents or their relatives on their behalf. A number of residents choose to bring items of furniture with them. Bedrooms are redecorated as they become vacant. The manager advised that the lounge is due to be redecorated in the next financial year. In addition to the lounge there is another room called the boudoir, which is used Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 17 for activities. The grounds are extensive and provide residents with ample space for walks during the summer months. Externally, the shutters have been repainted and ramps have been fitted to the building. All areas of the home were clean and fresh. Since the last inspection two portable bath chairs have been purchased. Each resident has their own cover for the chair. At the time of the last inspection five of the residents had indicated that they would like locks fitted to their bedroom doors. Locks were ordered but when delivered it was noted that they were not appropriate. This still needs to be addressed. The home had arranged for a fire risk assessment to be carried out within a few days of the inspection. It was noted that fire doors were propped open. The manager advised that this would be addressed as part of the fire assessment and if assessed as appropriate self-closing devices would be fitted. Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. The increased number and variety of training courses available to staff will ensure that there is a staff team well equipped to meet the needs of the residents accommodated. New staff receive a good induction to the home but the package should now be amended where appropriate to include all areas of the Common Induction Standards. EVIDENCE: At the time of inspection there was one care staff vacancy that had only just occurred. The manager advised that another member of staff was also due to leave at the end of the month. Both posts will be advertised. The home uses a mixture of, bank, agency or permanent staff doing extra hours to cover sickness. The manager advised that the ability to use agency staff is new to the Company. Since the last inspection a weekend cook had been employed but this position has become vacant again. There is a training plan in place to ensure that all staff receive mandatory training. Each staff member now has a personal development plan. Records showed a wide range of training had been provided for staff on a variety of subjects such as health and safety, professional boundaries, adult protection, fire safety, first aid, food hygiene, infection control, medication and moving and handling. In relation to the subject of death, dying and bereavement staff Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 19 had recently watched a video on the subject and this was followed by a general discussion. Further training on the subject had been planned but had been postponed by the trainer, to be held at a future date. Five of the fourteen care staff have completed NVQ at level two or above. It was reported that three are due to enrol within the next six weeks. The home has a detailed induction package for all new staff. The home needs to refer to the newly introduced Common Induction Standards to ensure that their package complies fully. As part of a new staff member’s probationary period staff must complete an initial induction checklist and there are a number of probationary meetings to monitor progress. The manager advised that they would shortly be introducing a questionnaire for staff to seek feedback from them on the induction process. Staff recruitment records were seen in relation to two staff members. Record keeping was detailed and all required checks had been carried out. In relation to one staff member it was noted that both references stated ‘yes’ to the applicant having criminal convictions but the CRB (Criminal Records Bureau) check was clear. The manager thought that this was an error but agreed to explore in more detail with the staff member. Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. 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. Peasmarsh Place is well run and staff feel well supported in their role. The home is working hard to ensure that all residents have an equal say in how the home is to be run. There are measures in place to ensure the health and safety of the residents and staff, however portable appliance testing must be undertaken to ensure the continued safety of the residents. Monthlyunannounced visits need to be reinstated to show evidence that the providers are being kept up to date with the running of the home. The Inspector is confident that the home is already working hard to address all the areas mentioned. EVIDENCE: Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 21 The manager and her deputy have both completed NVQ level four and the RMA (Registered Manager’s Award). Staff spoken with described the manager as ‘very supportive’. The management team share the responsibility for providing supervision to care staff. All senior staff have received training on the provision of supervision and the manager advised it is her intention to arrange further training in this area. A staff member spoken with stated that she finds supervision `helpful’ and that it is a good time to raise training wishes. She stated that she had had supervision the week prior to the inspection and she had asked for training in dementia. Since then a course has been arranged and will be held in the near future. Residents’ meetings are held on a regular basis and there is generally a good turnout for the meetings. Records show that there are good discussions regarding the food provided, daily activities and trips. It was noted that generally about 12 residents attend the meetings but that the same four residents tend to speak up at most at the meetings. Residents meetings were discussed with the Responsible individual after the inspection and they advised that they would do more one to one work with residents to seek their views in advance of the residents’ meetings and encourage them to raise their views during the meetings. Staff meetings are held approximately every six weeks. As part of the inspection process the inspector contacted three relatives of residents to hear their view about the home. Comments included ‘can’t fault the care’ and the care is very good, its 101 and I’m really pleased’ and ‘its excellent’. One relative stated that they were fully involved in the review of their relatives’ care plan and that the staff came up with some new ideas to try. She wasn’t sure if the new ideas had been implemented yet. One of the relatives spoken with stated that they had a few matters that they wanted to raise with the manager. The inspector met with a relative of a resident during the inspection and they described the care as ‘very good’. They also praised the home for the Friends and Families day, which was held during the summer months, and they stated that this was an excellent day and a great opportunity to spend time with their relative and to meet with other residents and their relatives in a very relaxed setting. One resident that is mostly bed bound spends a short period each day in a chair in their room. This resident was able to use a wheelchair for a short time recently to participate in a special event. When asked if this could be a regular occurrence staff advised that the home would need to seek specialist advice to see if the resident would benefit from more appropriate seating. A relative when asked if there was anything they thought could improve the quality of life for this resident thought that perhaps being able to use the wheelchair so that they could spend more time in the communal areas or even in the garden in the summer would be a good idea. Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 22 The manager advised that as part of their quality assurance system, satisfaction questionnaires were sent to the residents. The completed questionnaires were with the Responsible Individual at the time of inspection. It is over a year since questionnaires were sent to the relatives of residents, so this will be arranged in the near future. The inspector was advised that the pharmacy carry out a regular audit of medication. Health and safety checks are also undertaken periodically. There is a detailed quality assurance audit that was carried out in 2005. It was not clear if this audit is to be reviewed or if the new measures put in place would replace the original documentation. The home has no involvement in residents’ finances. Residents or their relatives on their behalf are invoiced directly for fees in relation to hairdressing and chiropody. The home’s policies and procedures manual has been completely updated and some new policies have also been introduced. All the policies and procedures are now specific to the home. The Responsible Individual for the home generally carried out monthly-unannounced assessments. It was reported that these have not been carried out for a number of months but that a new format for carrying out the assessments of the service are to be introduced. The format was seen and will allow for very detailed information to be recorded. It will be the responsibility of the manager from the sister home to assess Peasmarsh Place on a monthly basis and the Responsible Individual will also undertake periodic assessments. A Legionella risk assessment has been carried out and training was provided for staff on the subject. Hot water temperatures are tested on a weekly basis and all unused outlets are also flushed. Records showed that the gas was serviced in May 2006. Portable appliances were last tested in 2005. The manager advised that the equipment for testing portable appliances has been sent away for servicing and should be back within two weeks. Following receipt of this they will begin the task of testing all portable appliances. At the time of inspection the ground floor was being rewired. Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 2 2 Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14(1) Requirement Pre admission documentation must be detailed and available for inspection. Following assessment prospective residents must be informed if the home can/cannot meet their assessed needs. The Responsible Individual or a representative on their behalf must carry out monthly, unannounced visits to the home and to provide a copy of their findings to the manager. Copies of reports must be available for inspection. Arrangements must be made for portable appliances to be tested. [This was a requirement of the previous inspection timescale given 30/5/06]. Timescale for action 30/04/07 2. OP37 26 30/04/07 3. OP38 13(4)(a,c) 15/05/07 Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 25 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. 4. Refer to Standard OP7 OP19 OP30 OP33 Good Practice Recommendations Daily records should be used to document fully the action taken by staff to support residents. Where residents have chosen to have locks fitted to their bedroom doors, arrangements should be made for this to happen. The home’s induction package should be linked to Skills for Care and new staff should complete the package within twelve weeks of employment. Professional advice should be sought in relation to one resident as to whether they would benefit from having more appropriate seating that would enable them to use the communal rooms for short periods. Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Peasmarsh Place DS0000021186.V322318.R01.S.doc Version 5.2 Page 27 - 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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