CARE HOMES FOR OLDER PEOPLE
Peasmarsh Place Church Lane Peasmarsh East Sussex TN31 6XE Lead Inspector
Caroline Johnson Unannounced Inspection 6th October 2005 12.10 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.V255322.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 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.V255322.R01.S.doc Version 5.0 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.V255322.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. All service users should be older people aged 65 (sixty five) years and over on admission. A maximum number of 24 (twenty four) service users should be accommodated. 2nd February 2005 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. Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the first in the year running from April 1 2005 to March 31 2006. The inspection lasted from 12.10pm until 16.45pm. The registered manager facilitated the inspection. During the inspection there was an opportunity to meet with approximately seven residents. One member of staff was interviewed and another member of staff assisted with aspects of the inspection. A number of records were examined and plans for the care to be provided for two residents were seen. There was an opportunity to meet with a relative of a resident who was visiting at the time of inspection. A full tour of the building was not undertaken. However, a number of the bedrooms and the laundry and kitchen facilities were seen. What the service does well: What has improved since the last inspection?
In relation to the external building the south and west elevation has been repainted this year. All other areas will be repainted next year. One of the bedrooms has been repainted and a new shower fitted. A new alarm call system has been installed whereby residents carry a pendent with them so that they can call for staff assistance when required. In relation to fire safety the building has been divided into zones and magnetic doors have bee fitted in each zone. A number of staff have started or are due to start training for NVQ level two. All requirements and recommendations made at the last inspection of the home have been met. Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 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.V255322.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Prospective residents are given detailed information to help them make a decision about whether they would like to move to Peasmarsh Place. The manager carries out an assessment of the needs and abilities of prospective residents and this ensures that prior to agreeing to the admission of a new resident the home is fairly confident that they can meet the needs of the individual. EVIDENCE: There is a detailed statement of purpose in place. A copy of the statement of purpose is sent to all prospective residents. The current document includes reference to regular trips to Rye. The manger advised that trips are arranged when staffing levels allow. The wording of the document may be changed to reflect this position. The home carries out an assessment of all prospective residents prior to making a decision about accommodation. Record keeping seen in respect of one recently admitted resident showed that the home had been thorough in assessing both the abilities and needs of the resident. All new residents are issued with a contract of the terms and conditions of their residence. A number of residents spoken with stated that they, or a relative
Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 9 on their behalf, had visited the home prior to making a decision about accommodation. When asked why they chose Peasmarsh Place, one resident stated `because its streets ahead of all other homes in the vicinity’. Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9, Care plans include detailed information for staff to follow to ensure that residents’ needs are met. It is important that when residents’ needs change a risk assessment is introduced or reviewed as soon as possible. There are good arrangements in place for the storage and handling of medication. However, the home needs to ensure that there are risk assessments in place in respect of those residents who self-administer their medication. EVIDENCE: Three care plans were seen on this occasion. They included detailed information for staff to ensure that the residents’ needs could be met. However, in one of the care plans, due to the recent changed needs of the resident, a falls risk assessment needs to be introduced. The arrangements in place for the storage and handling of medication were satisfactory. Staff receive in-house training on the medication in use in the home. In addition an external trainer provides training to the staff team. A small number of residents self-administer their medication and a lockable facility is provided in bedrooms for this purpose. The manager advised that risk assessments had been carried out to determine if there were any risks that needed to be taken into consideration in respect of the self-administration
Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 11 of medication. However, the risk assessments could not be located on the day of inspection. On the day of the inspection an external trainer was in the home to provide training for staff on catheter care / continence. Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 Not all residents choose to participate in activities but for those that do there is a good range of activities on offer. Residents are provided with a varied and well balanced diet. EVIDENCE: There is a wide range of activities on offer in the home. A residents’ meeting is held monthly and residents are encouraged to suggest ideas for activities the following month. Activities include, arts and crafts, poetry reading, flower arranging and quizzes. In addition there is a mobile library that visits the home regularly. External entertainment is also arranged periodically. During the inspection there were four residents playing bridge. They stated that they enjoy playing bridge approximately four afternoons a week. Another resident stated that they enjoy gardening and help out regularly in the rose garden. There is a four-week menu in place, which is changed seasonally. A set meal is provided at lunchtime. Should a resident wish to have an alternative to the main meal then this is catered for and a record is kept of the alternative served. There is a choice of a hot supper, soup or sandwiches in the evening. Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 There is a detailed complaint procedure in place, which needs to be amended to advise that a complainant can contact the Commission at any stage of the complaint process. The home should document all issues of concern raised by residents along with the action they have taken to address the issues. EVIDENCE: Records showed that there had been no formal complaints. However, a Consultant visits the home, once a month on behalf of the proprietor, to monitor the conduct of the home. A report of these visits is written and copied to the proprietors, the manager and to the Commission. It was noted that on occasions during these visits residents have raised issues that could be classed as minor complaints. It was recommended that should this occur in the future, the manager should document the action taken by her to address the issues raised. There is a detailed complaint procedure in place. However it is recommended that the procedure be changed to state that the complainant may contact CSCI at any stage of the complaint process. Arrangements are made for residents to participate in political process such as voting at election time. This is mainly achieved via postal voting. One resident votes independently and the manager stated that should other residents wish to vote in person arrangements would be made for this to happen. Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 14 Staff have received in-house training in adult protection and prevention of abuse. The home’s procedure on adult protection needs to be expanded upon to include more detailed reference to the steps that would be taken should abuse be suspected. Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,24,26 The home is decorated to a high standard. There are extensive views across the countryside from most windows. Should a resident choose to have a key to their bedroom door then the current lock would need to be replaced with a more suitable lock. The arrangements in place in respect of fire safety have improved and further work is planned to in relation to the fire risk assessment. EVIDENCE: Externally the south and west elevation of the property has been repainted this year. All other areas are to be repainted next year. Five of the bedrooms are registered as double rooms. However, at the time of inspection all but one of these rooms was being used for single occupation. Not all rooms were seen during this inspection. Those seen were well decorated and had been personalised. Residents spoken with stated that they were very happy with the accommodation provided. Since the last inspection one of the bedrooms has been repainted and a new shower has been fitted. It was noted that there are locks on bedroom doors but that the locks do not comply with the national minimum standards. Should residents choose to use
Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 16 the lock on their bedroom door the lock would need to be replaced with a more suitable lock. A new call system has been installed. This involves residents carrying a pendent that they can operate when they need assistance. Residents spoken with stated that the new system was working well. Staff receive in-house training in fire safety. The manager advised that they are also going to arrange for an external trainer to provide training for staff. The home has a fire risk assessment in place. For fire safety purposes the home is divided into separate zones. Magnetic fire doors have been fitted in each of the zones. All areas of the home seen during the inspection were clean and there were no unpleasant odours. Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 Staffing levels are appropriate to meet the needs of the residents accommodated. Increased emphasis has been placed on staff training and arrangements have been put in place to achieve having 50 of the staff team trained to NVQ level two. EVIDENCE: The rota provided showed that staffing levels were satisfactory. There were two staff vacancies one for a relief cook and another for a waking night carer. Both positions had been advertised. Criminal records bureau checks have been carried out on all staff working in the home. Two staff members have completed NVQ level two. Three staff are currently studying for NVQ level two. Another three staff are due to commence training in the coming month and after Christmas another three will start studying. Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is well run with staff reporting that the management of the home are approachable and supportive. The home needs to document more clearly the action they have taken in respect of the quality assurance audit carried out in 2004. EVIDENCE: The manager and one of her deputies has completed NVQ level four in management. Staff spoken with during the inspection stated that the home was well run and that they find the manager very approachable and supportive. The manager and her deputies provide supervision to staff. Records showed that not everyone had regular supervision. The manager was confident that by increasing the frequency of the supervisions the home would get back on track with ensuring that all staff receive six supervisions a year. Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 19 The home’s previous Responsible Individual carried out a very detailed quality assurance audit in 2004. However, there was no written account of the action taken by the home in relation to the recommendations made. In June 2004 a questionnaire was sent to the relatives of the residents to seek their views on the quality of the care provided. The manager advised that she would be sending another questionnaire to relatives but that she may redesign the format for the questionnaire. Residents spoken with during the inspection all stated that the home was run well, that the food served was very good and that there was a good variety of activities to participate in. A visiting relative of one of the residents, spoke highly of the quality of the care provided to her relative and praised the staff team for their work. Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 20 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 3 X X 3 X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 3 X X Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 21 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 OP7 Regulation 13(4) Requirement In respect of one of the care plans seen a falls risk assessment must be introduced as discussed during the inspection. Risk assessments must be carried out to determine if there are any safety implications to be considered in relation to residents who self-administer their medication. A written record must be kept of the action taken by the home in relation to concerns (including minor concerns) raised by residents. Each resident must be given the choice of having a key to their bedroom door and a record must be kept of the decision. If they choose to have a key then the current lock must be replaced with a lock that can be opened from the inside without the use of a key. A written record must be kept of the action taken by the home in respect of the quality assurance audit carried out in 2004.
DS0000021186.V255322.R01.S.doc Timescale for action 15/12/05 2 OP9 13(2)(3)( b)(c) 15/12/05 3 OP16 17(2) Sch.4 para 11 12(3)(4)( a) 15/01/06 4 OP24 30/01/06 5 OP33 24(1) 30/01/06 Peasmarsh Place Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 6 7 Refer to Standard OP16 OP18 Good Practice Recommendations The complaint procedure should be amended to state that a complainant could contact the Commission (CSCI) at any stage of the complaint process. The home’s procedure for adult protection and prevention of abuse should be expanded to include more information about the steps that would be taken should an allegation of abuse by made. Peasmarsh Place DS0000021186.V255322.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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