Inspection on 06/09/07 for Peat Lane House

This inspection was carried out on 6th September 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Peat Lane House 07/02/07

Peat Lane House 26/06/06

Peat Lane House 20/03/06

Peat Lane House 06/09/05

Peat Lane House 16/03/05

Peat Lane House 29/09/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Peat Lane House Sandylands Kendal Cumbria LA9 6LA Lead Inspector Liz Kelley Unannounced Inspection 6 September 2007 10:00 th Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Peat Lane House Address Sandylands Kendal Cumbria LA9 6LA 01539 773073 01539 773073 peat.lane@cumbriacc.gov.uk www.cumbriacare.org.uk Cumbria Care 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) Mrs Heather Margaret Dixon Care Home 19 Category(ies) of Learning disability (18), Learning disability over registration, with number 65 years of age (1), Physical disability (5) of places Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available. The statement of purpose should clearly set out the physical environmental standards met/not met by the home in relation to standards met/not met by the home in relation to standards 24.2;24.9;25.3;27.2;27.4;28.2, and a summary of this information should appear in the service user`s guide. The home is registered for a maximum of 19 service users to include: up to 18 service users in the category of LD (Learning disabilities) of whom 5 service users may have a physical disability (PD). 1 person in the category of LD(E) (Learning disability over 65 years of age) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection to manage one home only. 7th February 2007 2. 3. 4. Date of last inspection Brief Description of the Service: Peat Lane House is registered as a Care Home for 19 people with learning disabilities of whom five may also have a physical disability. The registered provider is Cumbria Care, who are the Local Authority provider. The living accommodation is arranged into five separate flats accommodating between two and four people. Each flat had its own sitting room, fitted kitchen, bedrooms and bathroom facilities. The larger flats also have a separate dining room. A central laundry was available for some flats that do not have their own laundry facilities. The flats are linked by communal corridors and accessed via a shared entrance door and entrance hall, off which are staff offices. There is a staff sleep-in room situated upstairs. The Home also has a large separate communal lounge, which can be used by any of the residents. The Home has a respite facility, which is located in a separate flat that accommodates up to three people. Each flat has its own dedicated staff team who offer support, supervision and personal care. The current scale for charging is £501.81, and the level of contribution is determined through a financial assessment carried out by a social worker. This covers board, amenity bills, council tax and staffing costs. Residents are Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 5 expected to pay for transport, personal items, toiletries, clothes and social activities. A Handbook is available for prospective residents, the latest Commission for Social Care Inspection report is made available on request. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection looked at all the key areas of the National Minimum Standards, and checked on progress of the Improvement Plan requested by us as at the last inspection. Residents, and their families, and members of staff had given their opinions regarding the service and care to the inspector. These comments, and the observations made by the inspector, have informed the judgements made in this report. The inspector also: • Received questionnaires from professionals and other people working with the home • Interviewed the manager and spoke with staff • Visited the home, which included examining files and paperwork • Received a self-assessment report/questionnaire from the manager • Checked the Improvement Plan for the home Since the last inspection good progress has been made overall with the majority of targets being met and others being worked towards. There was a definite culture change noted with a more positive atmosphere both about the building and in staff and residents. The overall picture gained by the Inspector was that people were happy with their home and the care they received. On the whole relatives were also satisfied with the service but had two main areas of concern: staffing levels restricting social and leisure time; and inconsistency of the communications with the home. What the service does well: One of the strengths of the home continues to be the relationships that have developed between staff and people living at the home. Staff have knowledge, skills and training that enhances their work with residents. Residents said “ I like spending time with staff” and “I like the people I live with, my room is nice”. The stability and supportive nature of the staff group has helped them through a difficult period of change and given residents continuity of care. Staff said “ We have always been good at supporting one another and covering for each other to make sure that residents are not affected.” Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The introduction of new residents to the home is carried out to good standards ensuring that their needs can be met and consequently recent placements have been very successful. EVIDENCE: The manager follows the policy and procedure for the development of the Statement of Purpose and Service User Guide as stated by Cumbria Care, ensuring that it is specific to the home. The guide gives useful information on the homes aims and objectives, qualifications of the staff, how to make a complaint and feedback from results of the customer surveys. A copy is kept in each individual flat and individual copies are available on request. The manager is currently reviewing the information and guide given out to potential residents with a view to making them more user-friendly. This task has been allocated to one of the supervisors and a digital camera has been purchased to improve on the quality of information and to help people make informed choices. Results from the homes Quality Assurance survey sent to residents, families and other relevant stake holder to gain their views of the service is developed Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 10 into an action plan and the results can be found in the service users guide in the home. This gives people trying to choose a home good quality information and a real insight into the views and issues of people already living there. People recieve a licence agreement from the housing association along with terms and conditions of their residency which make it clear who is responsible for providing items or repairs in the home. These are done in pictorial format and copies of these are on held on each persons support plan. The manager and senior team have recently introduced a revised system for introducing a new resident whereby it carries out its own assessment of residents prior to individuals being offered a permanent placement. This is in addition to an assessment carried out by the social work team. Both documents on a person’s needs are used to draw up a plan of care. This has given the home more say and control over admissions and has helped with getting to know the person in much greater depth. This has ensured that more recent referrals have been carefully vetted to make sure the home can meet people’s needs and that the needs of those already living in the home are also considered. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning continues to improve resulting in greater choices and a better quality of life for residents. EVIDENCE: Each individual now has a new style of support planning which is more person centred and incorporates choices in the way people wish to be supported. They provide a holistic approach being developed around the individuals own needs and wishes. The plans are reviewed six monthly or annually or sooner dependant on the persons changing needs. These reviews gives people and their network of support the opportunity to be consulted about their needs and wishes for the service and support they require and action plans for the future are drawn up for staff to follow. The current action plans are discussed with other staff members at team meetings so everyone is aware of how to support individuals. The plans are drawn up by link workers with the individual and include input from significant people in the persons life. Staff are using various formats to Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 12 illustrate the outcomes using pictures, symbols and styles that are best understood by the individual. The link worker keeps the support plan up to date so that it is a living document. Staff are currently being supported by the manager, and through training, to be creative in the use of person centred plans, especially when supporting those with more limited ways of communicating. The manager is part of a working party to promote person centred planning and uses this to bring new ideas into the home. The support plans contain risk assessments for the individual to enable them to lead the life they choose. These are documented on Cumbria Cares risk assessment format. These include risk to health and safety and encouraging independence for the individual. A relative survey commented “ Provides a personalised service for each resident, taking account of their individual and group needs.” Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home has a strong commitment to supporting residents to make individual choices, some resident’s ability to have their chosen life style is still being compromised by inadequate staffing levels. EVIDENCE: It was reported at the last Inspection that the staffing levels in some of the flats were inadequate to meet the social and recreational needs of residents. A number of flats were only given two or three opportunities a week where staffing was increased to allow residents to go out. Since then the manager, with the support of the organisation, has looked at ways of improving this situation for residents. This has included how staff are deployed, and making better use of when staff can be doubled or tripled up to allow people to have one-to-one activities and for trips out of the home. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 14 The majority of people attend a day centre, and again the option not to do this is limited, although there are a number to chose from. Other people attended college courses or work placements and staff support them to find a service or course that suits them. Flexibility in people attending a day service is still somewhat limited and dictated by staff funding given to the home. Arrangements can be made if someone is unwell. This has the potential to improve with the “In Control” budgets due to be introduced, as referred to in the introduction. A relative survey form answered the question - Does the care service provide support people to live the life they choose? by saying “The only limiting factor is the number of staff available. With slightly more resources more could be done to provide enhanced opportunities.” A new way of assessing and funding is also being developed with social services, termed “In Control” and this has the potential for more choice to be given to the individual. This will mean that each service user is allocated an individualised budget, which they can then choose how to use to best meet their individual needs. This should increase opportunities and choices and enable them to develop the way they want their support to be delivered. These re-assessments are quite time consuming and the impact has yet to be felt in the home. People are supported to maintain and develop relationships, with relatives and friends. Some people are supported to visit their families. The home supports this with sensitivity and respect of each family’s circumstances. Relatives who returned comment cards as part of this inspection all commented positively on the support their relative receives from the staff team. Several of the more active residents have friendships with people from outside of the home who they have met at day services, college and social events. The person-centred plans show how staff support people to maintain important relationships. The meal arrangements are flexible and staff are able to respond to individual requests. Menus are planned with residents on a weekly basis and a communal evening meal is encouraged. Although there is a weekly shop for the each flat where residents choose to take part, individual shopping is also encouraged to develop independence and daily living skills. Details of residents being encouraged to have healthy diets were noted in care plans, and flats contain fresh fruit and vegetables. A resident spoken to was aware of foods that were good and others that she should try to avoid, and she said staff helped her to make these choices. A number of different evening meals were observed and varied from pasta bakes to jacket potatoes with various fillings, all served with salad. A relative commented “When I have been in at meal times the food has looked tempting and served attractively”. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each individual’s health and medication is carefully monitored ensuring that they have access to services that help to maintain good health. EVIDENCE: An inspection carried out by the pharmacy Inspector in January 2007, found that residents were protected by robust systems for medicines handling and record keeping. The service has systems in place so that medicines are given safely and good records are kept. Regular audits of medicines are done to ensure they are handled correctly and ordered when necessary so that they do not run out. Residents are able to take their own medicines if they wish, and following assessment, and are supported to do so. The home is developing Health Care Record booklets for each person. These have the potential to be very user-friendly and fit well into person centred planning (PCP), making use of symbols and pictures to illustrate. As with PCPs, Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 16 staff need to be given time to complete these documents, if they are to be useful working documents. Currently there are a number of different places that healthcare is recorded, including Health Care Booklets, and this can make it difficult to see what action and follow up is required. There needs to be a clear trail from identifying a health issue through to seeking advice, appointments etc, and the outcomes. Where appropriate this information should be communicated to relatives and a robust system developed to ensure that all messages are past onto each flat. Staff understand the key principles of giving personal support and are responsive to the varied and individual requirements of the residents. They recognised that the delivery of personal care is individual and must be flexible, consistent and reliable. Attention is given to ensuring privacy and dignity when delivering personal care and staff are sensitive to changing needs of residents. Whenever possible residents are able to have choice about who delivers their personal care, and this is recorded. Where possible residents are supported and helped to be independent and responsible for their own personal hygiene and personal care, and this is detailed in care plans. Staff are aware of the need to treat people with respect and to consider dignity when delivering personal care. People who use the service are happy with the way staff deliver their care and respect their dignity. This was also confirmed by relatives who had positive comments to make about the level of staff commitment to caring for their relative. There was evidence that staff were accessing specialist training to help them support residents, for example from local support groups and from healthcare professionals. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes policies and procedures ensure that residents are safeguarded from harm and their views and concerns are listened to, and acted upon. EVIDENCE: Residents have good and varied links with outside organisations and advocate groups which ensures that they have channels to express views and concerns if necessary. The manager and senior team also carry out an annual survey of residents which leads to an action plan to demonstrate how they have acted upon these views. Staff have received Adult protection training and demonstrate an awareness of the content of the policy and know the immediate action to take, and who to refer to. They have also received training in the use of physical intervention procedures, which focused on diversion tactics rather than physical restraints, these are not used. Polices and practices are followed that safeguard the handling of residents monies. Personal monies and records were examined and found to be correct, with the signatures of both staff and the resident. The service has a complaints procedure that is up to date, clearly written, and is easy to understand. It can be made available on request in a number of Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 18 formats (including other languages, large print, etc) to enable anyone associated with the service to complain or make suggestions for improvement. Residents were observed freely expressing opinions to staff. Residents said that they would feel able to speak to any of the staff and approach the manager with any issues they had and felt confident that any concerns would be sorted out. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there have been significant improvements to the building, the physical environment does not always meet the specialist needs of some residents with more complex needs. EVIDENCE: The layout and design of the building continues to present problems in meeting the needs of those with more complex needs. As mentioned in previous reports one flat in particular is over crowded, too small for its purpose and is of a poor design for anyone with mobility or behavioural issues. A local implementation group has been formed which includes representatives from relevant parties including service users and parent carers. Consideration should be given to providing each flat with a telephone to improve communications, as relatives often comment that they cannot get through via the office phone and messages are not passed on, and this creates a barrier for communication for people living in each flat. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 20 Even for those with good life skills the institutional nature of the building creates a barrier to integration into the community and labels individuals. All but one flat does not have direct access into the garden, and consequently this area is under used. This was commented upon by relatives and residents who could not have free access to safe outside space. The manager said she had applied to the Housing Association to have a new set of doors put in for one flat. A newly introduced Quality Assurance measure gives responsibility to individual flat teams to carry out routine checks at the end of each shift, and seniors are responsible for reporting any repairs necessary. This has made individuals more accountable for their work practices and this is followed up by regular spot checks by the manager and operations manager. A carpet cleaner has been purchased for the home and the carpets where clean and fresh. This has resulted in flats being generally cleaner, tidier and a safer home for residents to comfortably live in. The new system was judged to be working very well in providing a well-maintained environment. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are satisfied with the standard of care they receive from staff, but there are times when staff are not able to support them, when they want support. EVIDENCE: The service recognises the importance of training, and delivers a programme that meets statutory requirements and is working towards meeting the National Minimum Standards (NMS) for NVQ requirements. The service is also able to recognise when additional training is needed, and is usually able to arrange for this, as with the recent need to train staff further in Person Centred Planning and in the Care of Medicines. The home is steadily improving its number of qualified staff and now has 33 trained to at least NVQ level 2, this has moved from 25 at the last inspection. However this is still short of the target set by the NMS of 50 by 2005. The manager has recently developed a training programme and matrix for the home, and this allows for better monitoring, and targeting of shortfalls. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 22 Residents feel that staff are competent, trained and are generally satisfied that the care they receive meets their needs. However, there are times when staff are not able to support them, when they want support. This has the most impact on people’s social life and these concerns have been expressed in the section relating to leisure and social activities. Another relative stated “ In my opinion there does not seem to be enough staff on duty in order to allow a more active social life, especially at weekends, which leaves them looking a the same four walls”. The manager, within her remit, has looked at staff deployment and this has improved the situation as a temporary measure, until the new way of funding is introduced. Relatives were generally pleased with the staff group, one saying “Every member of staff is courteous, caring and relates very well to the relatives and friends of residents.” Staffing in the respite unit has been reviewed and now a regular group of relief staff are used, usually from the pool of staff already employed at the home, and this has improved consistency of care and ensures adequate staffing is provided to meet people’s needs. Shortfalls in staff files and supervision session identified at the last inspection have been met or are almost met. These staff files are now are well organised and kept up-to-date. Staff communication and supervision have been targeted for improvement. Regular individual supervision and team meetings now both have set agendas. This ensures that all important issues are covered by each flats team meeting and is used to disseminate information in a planned way. Supervision notes were examined and these worked best when the set agenda was followed. These supervisions were much more professional and focused on practice issues and training to develop new skills. A senior worker has now been given responsibility for relief staff supervisions and this has improved the frequency of support given to this staff group, who can often be over looked. One staff member said “ Staff morale is improving, communication and support have been better lately”. The manager has included staff supervision in the homes new Quality Assurance System and this is now carefully monitored for compliance by senior staff. The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home has improved with newly introduced systems that mean that it is efficient and well run. EVIDENCE: Management arrangements have been improved and strengthened. The manager now has sole responsibility for the home and the other service previously managed by her has now been allocated to a designated senior. The manager has also been given substantial support from her operations manager, they are both part of a senior management team set up to oversee the Improvement Plan. The home has developed a good Improvement Plan and has carefully monitored progress towards improving the quality of care given to residents Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 24 and to strengthen the administration of the home. The majority of surveys returned to CSCI reported a positive improvement, a smaller number still felt that communication could be improved and staffing levels also needed to improve. For example a couple of people mentioned the difficulty of getting through on the telephone, as there is only one central phone based in the supervisors office, and when messages are taken they are not always passed onto the flat in question. Other relatives said they would like to be informed when there was a change in staff looking after their relative. A new Quality Assurance system gives a framework for close monitoring of the quality of care delivered, health and safety matters and on staffing issues. For example the Operations manager targets three polices per month to review and audit to ensure they are being put into practice. In addition to this support workers are asked to complete a daily checklist at the end of each shift, that cover areas of health and safety - COSHH, fire, food hygenine and general cleanliness. This is monitored by the supervisor allocated to each flat and spot checked by the manager and Operations manager. The manager demonstrates a commitment to improving the service, for example by playing an active part in groups that promote good practice such as the Person Centred Planning Champions group and the Health Facilitation group. The manager has introduced a number of systems to improve communication with staff; this has included more structured supervision sessions and team meetings that address important changes and proposals for the future. Ways of keeping relatives updated and briefed in a timely fashion have also been developed, as demonstrated by the recent Consultation evenings, and parent carers and relatives being invited onto the Project Group regarding the future provision of care at Peat Lane House. Similarly residents have also had a group set up which is called “The Bluebell Group”, which has recently successfully applied for funding for a computer with internet access for the main lounge for residents use. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 26 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 YA13 Regulation 18 Requirement There must be sufficient staff on duty to allow for residents to follow individual activities and have choice in how they spend their time Previous deadline set at 31/03/07 Timescale for action 30/12/07 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 YA24 Good Practice Recommendations Consideration should be given to providing each flat with a telephone to improve communications. Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Peat Lane House DS0000036525.V339544.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!