Inspection on 01/08/05 for Peregrine House

This inspection was carried out on 1st August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Peregrine House 29/08/07

Peregrine House 19/10/06

Peregrine House 02/12/05

Peregrine House 04/10/04

Peregrine House 08/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE PEREGRINE HOUSE 350 Hermitage Road South Tottenham London N15 5RE Lead Inspector Peter Illes Unannounced 1 August 2005 @ 9.40 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Peregrine House Address 350 Hermitage Road, South Tottenham, London N15 5RE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8809 5484 020 8802 1471 Peter Snelling for Servite Houses Ms Yvonne E Smythe PC - Care Home 35 beds Category(ies) of PD(E) - Physical Disability - over 65 registration, with number MD(E) - Mental Disability of places OP - Old age PD - Physical Disability PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 35 people of either gender who fall into the category of old age (OP); 2. And who may also h ave a mental disorder (MD(E)) and who may also have a physical disability (PD(E)). 3. Up to 16 of the 35 places may accommodate people of either gender who are aged between 40 and 65 years of age and have a physical disability (PD). Date of last inspection 4 October 2004 Brief Description of the Service: Peregrine House is a large care home for up to thirty-five service users, the majority of whom are older people but there is a significant group of younger service users with physical disabilities. The home is run by Servite Homes. The home is located in a residential road in South Tottenham. It is sited close to local shops, public transport and local amenities. The home is organised over two floors, with the ground floor functioning as a specialist unit for up to sixteen younger people with physical disabilities. All bedrooms are for single occupancy and have en-suite facilities. There is a lift and a number of assisted bathrooms. There are patio areas with raised tubs which are accessible to service users. The stated aims of the home are:‘Peregrine House offers care and support to enable residents to remain as independent and active as possible. Each person is treated as an individual with his or her own likes and dislikes.’ The home provides twenty-four hour care and support and access to a range of residential specialist services geared towards meeting individual service users needs. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took approximately six and a half hours. The registered manager was on leave although the homes administrator, the senior member of staff charge on the early shift and the assistant manager, who was in charge of the late shift were all very helpful throughout the inspection, especially the administrator. The inspector met and spoke to the majority of the service users, five independently, and independent discussion with three care staff. The inspector also spoke independently by telephone to the responsible individual of the provider organisation. Further information was obtained from: a tour of the premises; the pre-inspection questionnaire; a significant amount of comment cards- twenty three from service users, four from relatives, four from care managers/ placement officers and one from a health/ social care professional and a range of documentation kept at the home. What the service does well: What has improved since the last inspection? There were twenty requirements at the last inspection and all but one of these had been met. The improvements made were in a number of different areas: maintenance of the building, health and safety, records kept, recruitment, staff support and complaints. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 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. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Prospective service users can be confident that their needs will be assessed prior to their admission to the home to ensure those needs can be effectively met. Their needs continue to be reviewed if they are admitted to ensure that their changing needs will also be able to be met. EVIDENCE: Four service user files were inspected. Each had satisfactory assessment information with evidence to confirm that this information had been received by the time the person was first admitted to the home. There was also evidence that the individual’s needs were reviewed on a regular basis and changing needs recorded. The home operates a key worker system and staff spoken to confirmed that they were involved in regular reviews for the service PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 9 users they were key worker for. Service users spoken to were able to confirm that they attended their reviews. Some were also able to confirm that they had contact with their social workers at reviews, others were not able to confirm this. The home operates two respite beds and previous correspondence between the provider organisation and the CSCI indicates that these are not used as intermediate care beds. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Service users needs are well set out in their care plans to ensure their current assessed needs are being addressed. Service users health needs are well monitored and service users are supported in addressing these with relevant health professionals. The policies and procedures for the safe and secure handling of service users medication are in place to ensure service users medication needs are met although the practical implementation of these needs to be improved. Service users receive sensitive support with their personal care from staff and are treated with respect by them. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 11 EVIDENCE: Four service users care plans were inspected and each was current and comprehensive. There was evidence that the care plans had been regularly reviewed, monthly for older people and at least six monthly for younger adults. There were also current risk assessments with evidence that these had been reviewed on a regular basis as with the care plans. Risk assessments seen included moving and handling assessments and risk assessments for those service users that smoke, the latter being required at the last inspection. There was evidence that service users health needs are satisfactorily addressed, this was recorded on the service user files inspected. This included that service users were registered with a GP and relevant appointments had been attended by individuals with healthcare professions such as chiropodist, optician and planned hospital outpatient appointments. Service users medication and medication administration record (MAR) sheets were sampled on two of the four units. There was evidence that one identified medication for an identified service user had been administered on the day of the inspection although the rest of that medication could not be located in the medication cupboard on that unit. A requirement is made regarding this. Service users spoken to stated that the support that they received from staff was generally very good. One service user explained how they were assisted with their personal hygiene and was satisfied with the way this had been done. One service user spoken to stated that he felt staff could be awkward at times. The service user could not give an example of what awkward meant and said that they did not have a problem at the moment. On further discussion with staff it was not possible to identify any issues that may have led to the remark. The inspector observed staff interact with service users throughout the inspection and they were seen to treat service users with respect during that time. A number of service users spoken to confirmed that they had keys to their rooms and could choose when to be in company and when to be alone. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with asssistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 The home provides a range of social and other activities to meet service users needs and wishes. Service users are supported to maintain and develop relationships with their relatives and others to the extent that they wish. The home supports service users to make as many decisions for themselves as they can. The home serves varied and healthy meals that most service users enjoy although the choice needs to be expanded to include more choice to meet the preferences of service users from ethnic minorities. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 13 EVIDENCE: A number of service users attend external day services and a weekly programme of activities run by the home was seen displayed on the notice board by the entrance foyer of the home. Service users were seen to be being supported by staff in playing indoor board games and some service users watched a film on DVD during the inspection. One service user indicated that they enjoyed the music and dancing sessions organised on one of the units. The inspector was informed that the home had acquired a snooker table at the request of some service users. This was seen although was not being used at the time. A number of service users had recently been on a visit to Canterbury in Kent and photographs of the trip were seen displayed in the home. The inspector was informed that the provider organisation was planning a holiday during August and some of the service users from the home were going on this. One service user spoken to was keen to tell the inspector that they were supported to go to church on a Sunday. Staff told the inspector that service users were encouraged to have contact with relatives and friends to the extent that they wish and some service users spoken to confirmed this. Service users confirmed that they are able to entertain visitors in their rooms or in other identified private places within the home. The home’s visitor’s book indicated that the home received numbers of visitors on a daily basis. Evidence was seen that the home holds regular service user meetings every two months and a relatives meeting every six months. Some service users, mainly younger adults, spoken to were satisfied with the level of input they had over their environment and opportunities to make decisions while others were more non committal. Most said that they knew who their key worker was and had a regular chance to discuss issues with them. A staff member gave the example of the purchase of the snooker table as a concrete example of service users views being listened to. The inspector’s overall impression was that there were both formal and informal opportunities for service users to make their views known and that there was a commitment from staff to support service users in this respect where possible. An outside contractor, which is linked to the provider organisation, provides the main meals at the home. The inspector spoke independently to the chef on duty who stated that the relationship with the home’s own staff was positive. The main kitchen was inspected and found to be clean and tidy. A satisfactory record of fridge and freezer temperatures was seen. Food was stored appropriately in the main kitchen, was within its use by date and matched the planned meals on the menu. There are kitchenettes in each of the four service user units where breakfast and snacks can be prepared by service users and by staff for service users. In the fridge in the kitchenette on one of the units was a plate of corned beef that was covered but not dated. A requirement had PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 14 been made at the last inspection that all food that had been stored after being removed from its original packaging must be clearly labelled including a use by date. This requirement is restated. The chef confirmed that she met with the registered manager on a regular basis to discuss any current issues. She also stated that the company prepares menus, which included an alternative for each main meal, for approval by the provider organisation and that service users are consulted about meals at service user meetings. The lunch options looked appetising on the day of the inspection and most service users spoken to stated that they enjoyed the meals at the home. One Afro-Caribbean service user however was eating a takeaway meal for his lunch and said that the food served by the home was awful. On further discussion the service user indicated that he preferred West Indian food and that this was not available. Staff spoken to independently stated that the situation was complex because this service user needed a restricted diet because of a medical condition. A requirement is made that suitable alternative options are identified to meet the preferences of service users from ethnic minority communities and that these are included as an option on the menu on a regular basis. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these three standards were inspected on this occasion. EVIDENCE: Although these standards were not inspected on this occasion confirmation had been received by CSCI outside of the inspection that two requirements made at the last inspection relating to identified issues in this section had been complied with. It was also noted that the home had a satisfactory complaints policy clearly displayed in the entrance foyer to the home. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 Service users live in a home that is generally well decorated, well maintained and that meets their needs although identified routine maintenance items need to be attended to. Ventilation arrangements in an identified area of the home should also be reviewed. The home was clean and tidy throughout creating a pleasant environment for service users, staff and visitors. EVIDENCE: The home is purpose built with service users living within one of four semi selfcontained units, two on the ground floor and two on the first floor with a lift to PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 17 assist access to the first floor. The inspector was pleased to see that requirements made at the last inspection regarding refurbishing the four assisted bathrooms and the replacing of identified window frames had been complied with. The home is generally safe although urgent attention is needed to the fire detection system and this is dealt with more fully in the management and administration section of this report. The home is generally well maintained and decorated although a door to the outside of the home from the red unit would not open. This door was not a fire exit and identified means of escaping the unit in the event of fire were clearly labelled and appropriately labelled. A requirement is made regarding the door. It was also noted that in the blue unit a toilet seat needed replacing and a requirement is made regarding this. During discussion with the chef the inspector was told that the kitchen can become very hot and stuffy in the kitchen when the weather is hot. A recommendation is made to review the ventilation arrangements in the kitchen The home was clean, tidy and free from offensive odours during the inspection. The home had a satisfactory laundry and new washing machines had been fitted that were seen to meet the requirements of this standard. Laundry was being undertaken during the tour of the premises and the process was explained to the inspector including that each service user’s laundry was washed individually. Staff spoken to were knowledgeable about infection control procedures and suitable arrangements were in place to deal with soiled laundry and to dispose of other soiled material. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 The home has an effective and stable staff team, in sufficient numbers, to support service users and to assist in meeting their assessed needs. Identified documentation relating to staff recruitment needs to be retained to evidence that service users are properly protected by the homes recruitment policies. EVIDENCE: The staffing for the home consists of six staff on the early and late shifts with one staff member being allocated to each of the four units and two staff floating between the units. Three waking night staff cover the four units between them of a night. The staff rota was seen and matched the staff that were on duty. One staff member told the inspector that they could be very busy at times and felt that on occasions more staff would be helpful. Given the needs of the current service users the inspector’s view was that the staffing level for the home was adequate although accepts that staff can be busy on occasions. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 19 No new staff had been employed since the last inspection so the standard relating to staff recruitment was not fully inspected. The inspector was given a list of enhanced criminal record bureau (CRB) checks for all staff and those sampled were satisfactory. The inspector was informed that enhanced CRB’s were obtained by the provider organisation for all new staff although once seen at the provider’s head office they were destroyed and were not seen at the home. A requirement is made that enhanced CRB’s must be retained by the provider organisation until the CSCI inspection following the recruitment of any new staff to enable confirmation to be made if required that these are satisfactory. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s polies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 33, 35 and 38 (Older People) and Standards 23, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Defective equipment for detecting fires in the home needs repairing and interim arrangements urgently put in place to fully protect service users and others that work or visit the home from the risk of fire. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 21 EVIDENCE: A significant issue at this inspection was that the fire detection system on the ground floor of the home could not be tested due to a recent fault in the system. Evidence was seen that this had been reported to the company that maintains the system but apparently the company were having difficulty obtaining the necessary part to make the system testable. The company responsible had allegedly told the home that the system would still work although it could not be tested. The inspector was informed that the company declined to confirm this in writing when requested on the day of the inspection. Due to this an immediate requirement is made that: the fire detection system is fully repaired, in the interim battery operated smoke detectors are fitted in all ground floor rooms, that hourly visual checks are made of all the ground floor areas and a record kept of these checks, a risk assessment is undertaken of these interim arrangements when in place and confirmation sought from the fire officer that the above arrangements are satisfactory and any additional requirements that may be made by the fire officer are complied with. During the tour of the building it was noted that some service user’s bedroom doors, which are fire doors, were wedged open. The inspector was informed that this was because those service users were adamant that they did not want their doors kept shut. A requirement is made that the home must also ensure that risk assessments are completed on all service users that request their bedroom doors to be kept open and that all these arrangements are agreed with the fire officer. During the tour of the premises several fire doors were tested in the communal areas of the building. These doors were held open by electro-magnetic devices linked to the fire alarm. The majority of these closed satisfactorily and stayed closed when tested. Identified doors however had a roller type catch to hold them closed when shut; although these did shut satisfactorily they would push open again at the slightest pressure. A requirement is made regarding this. The home’s overall fire risk assessment and emergency fire plan were not available for inspection. A requirement is also made regarding this. Evidence was seen that the homes fire alarm and fire fighting equipment had been satisfactorily serviced. No other health and safety documentation was inspected on this occasion. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 22 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 x 2 x 3 3 4 x 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 2 x x x x x x 3 Score Standard No 7 8 9 10 11 Score 3 3 2 3 x Standard No 27 28 29 30 3 x 3 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score x x x MANAGEMENT AND ADMINISTRATION Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x 37 x 38 1 PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13(3) Requirement The registered persons must ensure that all medication for service users is kept in the medication cupboard in the unit where the service user is accommodated. The registered persons must ensure that all food that is stored after being removed from its original packaging must be clearly labelled including with a use by date. (timescale of 30/11/04 not met) The registered persons must ensure that that suitable alternative meal options are identified to meet the preferences of service users from ethnic minority communities that these are included as an option on the menu on a regular basis. The registered persons must ensure that an identified door in red unit is able to open and shut effectively. The registered person must ensure that an identified toilet seat in blue unit is replaced. The registered persons must ensure that enhanced CRB’s are Timescale for action 31/8/05 2. 15 13(4)(i) 31/08/05 3. 15 16(2)(i) 31/8/05 4. 19 23(2)(b) 31/8/05 5. 6. 19 29 23(2)(b) 19(5), Sch.2(7) 31/8/05 31/8/05 PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 24 7. 38 23(4) retained by the provider organisation until the CSCI inspection following the recruitment of any new staff to enable confirmation to be made if required that these are satisfactory. The registered persons must ensure that: a) the fire detection system in the home is fully repaired; b) in the interim battery operated smoke detectors are fitted in all ground floor rooms; c) hourly visual checks are made of all the ground floor areas and a record kept of these; d) a risk assessment is undertaken of these interim arrangements when in place and confirmation sought from the fire officer that the above arrangements are satisfactory and any additional requirements that may be made by the fire officer are complied with. IMMEDIATE REQUIREMENT a) 12/8/05 b) 2/8/05 c)1/8/05 d) 2/8/05 8. 38 23(4) 9. 38 23(4) 10. 38 23(4) The registered persons must 31/8/05 ensure that risk assessments are completed on all service users that request their bedroom doors to be kept open and that all these arrangements are agreed with the fire officer. The registered persons must 31/8/05 ensure that all fire doors that are held open with electro-magnetic devices close effectively and stay closed when activiated. The registered persons must 31/8/05 ensure that the home has a satisfactory fire risk assessment and emergency fire plan available for inspection in the home at all times. Version 1.40 Page 25 PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc 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 19 Good Practice Recommendations The ventilation arrangements in the main kitchen should be reviewed. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London, N14 6HA 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. PEREGRINE HOUSE G59 S10734 Peregrine House V221022 01.08.05 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!