Inspection on 09/02/06 for Peasmarsh Place

This inspection was carried out on 9th February 2006.

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

Peasmarsh Place 26/02/09

Peasmarsh Place 15/03/07

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 Unannounced Inspection 9th February 2006 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.V273600.R01.S.doc Version 5.1 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.V273600.R01.S.doc Version 5.1 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.V273600.R01.S.doc Version 5.1 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. 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.V273600.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second inspection in the year running from April 1 2005 to March 31 2006. The inspection lasted from 10.00am until 15.00pm. The registered manager facilitated the inspection. During the inspection there was an opportunity to meet with two residents in private and with one visitor to the home. Two members of staff were interviewed in private. A number of records were examined including the plans for the care to be provided for three residents. In addition records were seen in relation to staff recruitment, menus, medication and health and safety. What the service does well: What has improved since the last inspection? What they could do better: Six requirements were made as a result of this inspection. The home needs to include more detailed information in care plans and to introduce more risk assessments to determine if there is any further action the home could be Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 6 taking to minimise further the risk of accidents and incidents. They need to review the system in place for administering and recording medication in use in the home to prevent errors occurring. They need to provide a portable bath chair for residents that have difficulty with getting in/out of their baths. They need to carry out their quality assurance audit. They need to ensure that all staff receive six supervisions annually and in relation to health and safety, the home needs to make arrangements for the gas to be serviced, portable appliances tested and the water tested in relation to legionella. 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.V273600.R01.S.doc Version 5.1 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.V273600.R01.S.doc Version 5.1 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): These standards were not inspected on this occasion. EVIDENCE: Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 9 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): 7,8,9,10 The information provided in care plans is good but should be more explicit in detailing the actions required by staff to meet the needs of the residents. The home needs to carry out more detailed risk assessments in relation to meeting the individual health and safety needs of each resident. A number of poor practices were highlighted in relation to the medication procedures. The home’s procedures are not being followed. They need to be reviewed as soon as possible and all staff informed of the procedures to be followed. EVIDENCE: Three care plans were seen on this occasion. The information provided is good and there is advice for staff to follow to ensure that the needs of the residents can be met. A good example of this is in relation to one resident who is partially sighted. There is a care plan advising that staff ensure that the colours of the plates used at meal times are different for each course and that there is a contrast between the tablecloth and the colour of plate. However, particularly in relation to residents who are more dependent, there is very limited information provided on the level of care and support to be provided. Residents spoken with stated that they are treated with respect. Staff knock on the door prior to entering. A friend of a resident who was in the home Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 10 during the inspection stated that staff are very good at ensuring that her friend’s clothes are well co-ordinated and that she looks well. As recommended at the last inspection of the home the manager has carried out a detailed falls risk assessment in relation to one resident’s needs and the resident concerned has also signed the assessment. At the time of inspection there were two residents who were considered to have high dependency needs and two residents whose healthcare needs were changing and assessments were being carried out to determine if the home could continue to meet the needs in line with their registration. The District nurse holds a clinic in the home once a week and in addition she visits two of the residents on a more regular basis. It was noted at 11.00am that the medication administered earlier in the day had not been signed as having been given. When this was pointed out to the manager the carer then signed the medication records. Records showed approximately one week prior to the inspection a resident refused one of her medications. There was a note on the back of the chart advising that this would be discussed with the relevant doctor. Records for the following days were blank. The manager stated that she had spoken with the doctor who advised that staff continue to offer the resident this medication. However although this was written in the accountability records it was not included on the MAR (medication administration record) chart and there was no evidence that the medication had been offered to the resident. Records also showed that there was a drug error on one occasion. The manager advised that she sought advice from a visiting doctor on the day the error occurred. However the advice obtained was not recorded. The Commission was not informed of the drug error. All other records seen were in order. Since the last inspection risk assessments have been carried out in relation to those residents who selfmedicate. In each case the relevant general practitioner and the residents have also signed the risk assessments. One resident self-administers oxygen. The manager reported that staff have also received training on the administration of oxygen. Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 11 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): 12,13,14,15 There is a good range of activities in place for residents to participate in. The menus are varied and the feedback from residents and visitors was that the quality of the food served is very good. The home is good at seeking residents’ preferred choice of meal at breakfast and supper. In relation to lunch time the system in place works for those who check the menu board. The home needs to find a way of ensuring that residents are given plenty of notice of the set meal for each day so that they can make a different choice if it is not to their taste. EVIDENCE: The manager is exploring the possibility of having a loop system in place to assist those who have a hearing impairment when they participate in group activities. Visitors are welcome to the home at any reasonable time. Residents confirmed that their visitors are made very welcome to the home. Some of the residents run a bridge group four times a week. They also invite friends from the wider community to some of the bridge sessions. A staff member advised that other activities in the home include, poetry reading, movement and music, crafts, painting and flower arranging. There are trips out for lunch and to places of interest and every few months, a mobile clothes shop comes to the home. Residents spoken with stated that they choose whether to join an activity or not. Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 12 One of the residents spoken with stated that `the food is excellent’. She said that in the past it was not good but in the last couple of years it had really improved. The manager advised that following issues that were raised by residents in the past, the menus were changed and they changed suppliers and they seldom have complaints about the food now. Another resident spoken with stated that there was a set meal at lunchtime and she wasn’t sure if she could have an alternative. She stated that she didn’t always know what was on the menu until she went to the dining room. Records showed that residents do have alternatives to the main meal. There is a four-week menu in place, which is changed seasonally. A card is left on meal trays daily so that residents can choose an alternative breakfast choice. The main meal is displayed on a menu board and the manager reported that staff advise the residents that do not come downstairs prior to the lunch of the meal to be served daily. The supper menu includes a choice of soup, sandwiches, salad and/or hot meal. Alcohol is served with lunch and supper as desired. The menus seen showed variety and were well balanced. Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 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 The system for recording complaints has improved and now even minor complaints are recorded. To improve the system even further the home should record that they have checked with complainants that they are happy with the outcome of their complaint. EVIDENCE: The home has introduced a new format for the recording of minor complaints. Since the last inspection of the home there were two minor complaints recorded. Records were detailed showing the action taken by the home to address the issues raised. Records do not show if the home had checked with the complainant if they were happy with the outcome. The home’s complaint procedure has been amended to show that the Commission can be contacted at any stage of the complaint process. Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 14 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 The provision of appropriate locks on bedroom doors is considered good practice. Although staff cannot be held responsible for ensuring that call pendants remain with residents at all times they should routinely ensure that the pendant is located close to the resident when they leave their room and that the resident is advised of the location. As the home does not have a communal assisted bath they need to have a portable bath chair to assist those residents who have difficulty-getting in/out of their bath. EVIDENCE: The manager reported that since the last inspection of the home she had sent a memo to all residents advising that a lock would be provided on their bedroom doors if they chose to have one fitted. Approximately five residents indicated that they would like a lock to be fitted to their door and the manager confirmed that the locks had been ordered. It was noted in one of the bedrooms that the resident’s call pendant, which is used to alert staff when a resident requires staff assistance, was the opposite side of the room to a resident who is partially sighted. Although the resident Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 15 may have left the pendant there, there should be a risk assessment in place advising staff to check that the call pendant is close to the resident at all times so as to minimise the risk of accidents occurring. All of the bedrooms have ensuite facilities so there is no communal bathroom. The home has one bath chair and two bath knights. Another resident advised that she paid for her own bath chair. Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 16 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): 27,28,29,30 Staffing levels at the time of inspection were appropriate to the needs of the residents. There are good recruitment procedures in place and good training opportunities are provided for all staff. EVIDENCE: On the day of inspection the manager was on duty assisted by a senior carer, three carers, two housekeepers, one cook, one domestic and one laundry assistant. There were nineteen residents in the home. Two staff had almost completed their induction to the home. Recruitment records were seen and included application forms, references and identification. The manager advised that they continue to have a vacancy for a relief cook. She will re-advertise this position and will also advertise for bank staff. The manager advised that first aid training had been booked recently, but due to staff sickness it had to be cancelled and will be rebooked. Staff have attended training on medication, fire safety and food hygiene. The manager and her deputy have completed NVQ level four, two care staff have completed level two and another two staff are currently working towards level two. Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 17 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): 32,33,36,38 Although formal supervisions are not held as often as is required, staff feel well supported and can go to the manager at any time if they have a problem. The residents spoken with were very happy with the care and support provided to them. It is essential that a new quality assurance audit be carried out. In order to safeguard against the risk of accidents/incidents, arrangements also need to be made to have the gas serviced, the portable appliances tested and the water tested in relation to legionella. EVIDENCE: Staff spoken with during the inspection described the manager as `very supportive’. One carer said that she liked working in the home because `the standards were high’, she also said that she wouldn’t work anywhere else’. Another carer said that `staff are encouraged to share ideas and to have their say at staff meetings’. The manager advised that she discussed the requirement made at the last inspection of the home in relation to quality assurance with the newly Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 18 appointed general manager. They agreed that rather than concentrating on the last quality audit that was undertaken some time ago they would revise their procedure for undertaking quality assurance and start afresh. Residents spoken with during the inspection talked very positively of the care and support they receive. One resident in particular commended the staff for the quality of the care given to her when she had been very ill. There was also an opportunity to speak with the friend of a resident who advised that the care provided to her friend was very good. The manager advised that they were behind with the provision of staff supervision. She has spoken to staff at the last staff meeting and advised that she will set aside protected time to do supervisions in the future. She reported that the new General Manager has also agreed to provide training for the manager and senior staff on the provision of supervision. In relation to health and safety, records showed that the fire alarm system and emergency lights were serviced in December 05, and the hoist and lift were serviced in October 05. Arrangements need to be made to have the gas serviced, portable appliances tested and the testing for legionella carried out. Two of the staff team had recently been delegated as health and safety representatives for the home and one of their first tasks is to carry out a detailed individual room risk assessment. The manager advised that a new General Manager has been appointed. She has met with the residents and joined one of the senior staff meetings. During this meeting she highlighted how she hopes to work and the areas that she will concentrate on in the first few months of her employment. One of these areas is the updating of the home’s policies and procedures. The manager described her as `very supportive’. Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 19 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 3 X X 2 X X X X 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 X 3 2 X X 2 X 2 Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 20 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. 1 Standard OP7 Regulation 15(2) 13(4)(a,c) Requirement In relation to residents that are more dependent on staff for support, care plans must provide more explicit information about the level of care to be provided. The home must carry out more detailed risk assessments in relation to meeting the individual health and safety needs of each resident. In relation to the safe handling of medications the manager must ensure that: The home’s procedure for the administration of medication must be reviewed and all staff must follow the updated procedure: The arrangements for recording when medication has been refused must be reviewed: Any incident affecting the well being of a resident must be reported to the Commission (this includes drug errors) and the home must keep detailed records of the action they have taken. Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 21 Timescale for action 30/04/06 2 OP9 13(2), 37(1)(e) 30/04/06 3 OP22 23(2)(n) 4 5 6 OP33 OP36 OP38 24(1) 18(2)(a) 13(4)(a,c) The home must provide a portable bath chair to assist those residents that have difficulty when getting in/out of the bath. Once updated, the homes quality assurance audit must be carried out. All staff must receive supervision at least six times a year. Arrangements must be made for the following to be serviced/tested: - gas, portable appliances and testing for legionella. 30/05/06 30/06/06 30/05/06 30/05/06 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 OP15 Good Practice Recommendations The home should formalise the system already in place to ensure that all residents are advised of the daily main meal well in advance so that if it is not to their liking there is time to order an alternative. The home should check with complainants that they are satisfied with the action that has been taken by the home in response to their complaint. Staff should ensure that whenever they leave a bedroom they make sure that the resident has access to their call pendent. 2 3 OP16 OP22 Peasmarsh Place DS0000021186.V273600.R01.S.doc Version 5.1 Page 22 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 © 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.V273600.R01.S.doc Version 5.1 Page 23 - 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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