Inspection on 15/12/05 for Peregrine House

This inspection was carried out on 15th December 2005.

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 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 08/12/06

Peregrine House 23/02/06

Peregrine House 26/01/05

Peregrine House 22/09/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Peregrine House 48/52 Upgang Lane Whitby North Yorkshire YO21 3HZ Lead Inspector Gill Sample Unannounced Inspection 15th December 2005 10:30 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 Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Peregrine House Address 48/52 Upgang Lane Whitby North Yorkshire YO21 3HZ 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) 01947 603886 01947 606663 peregrinehouse@yahoo.co.uk Aikmo Medical Limited Mrs Alison Jane Bedford Care Home 27 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (10), Old age, not falling within any other of places category (27) Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The category (DE) refers to service users over the age of 60. Service users in the category (DE) only if the predominant care need is due to a mild or moderate dementia in accordance with the homes` statement of purpose. 26th January 2005 Date of last inspection Brief Description of the Service: Peregrine House provides long-term accommodation and personal care for a maximum of twenty-seven older people. The home provides a specialist service to people with dementia who are cared for alongside other residents. If capacity permits people may be admitted on a short-term or respite care basis. The home is in a residential area of Whitby and is conveniently located for all main community facilities. It does not have its own parking facilities but ample on-road parking is readily available. It is a traditional building constructed during the late Victorian period. It was originally three properties which have been converted into one. Peregrine House is built on three floors with service users’ accommodation on each floor. The main communal areas, such as the dining room, are located on the ground floor. Peregrine House has a number of small lounge areas situated on the upper floors thereby giving the service users a choice of communal space. The home has twenty-three single and two shared or double bedrooms, all of which have en suite facilities consisting of a toilet and a wash hand basin. There is a passenger lift to all floors that can transport a wheelchair user and their helper. The home has large lawned gardens that have appropriate seating for the service users. Several ‘windbreaks’ have been built in the garden so that people can sit in comfort and privacy. Ramps with handrails lead to all the main entrance doors. Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report gives the findings of an unannounced inspection which was made on 15th December 2005. The inspection focussed on a number of key standards and those requirements and recommendations made at the last inspection. There were 23 residents living at the home of whom six had a diagnosed dementia. Some of the premises were inspected including a number of bedrooms, bathrooms and living areas. A range of written records were also examined. Residents were spoken with both individually and in small groups and five of these service users’ records were examined. Discussions were held with registered manager and staff at the home and with Mrs. Teresa O’Sullivan, a Director of the company which owns and operates the home. What the service does well: What has improved since the last inspection? The home has had a change to its registration since the last inspection so that it can care for people with a diagnosed dementia. There were six people with dementia type illness living at the home at the time of inspection who are cared for alongside other residents. Some progress has been made in sourcing suitable locks to be fitted to service users’ rooms. The registered manager has achieved the Registered Manager’s Award and is currently studying for the qualification in care. Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply. Prospective residents are provided with information about the home which includes the services and facilities offered by the home and how their needs would be met. Details of needs are gathered and recorded prior to any person being admitted to the home so that they can be assured these can be met. EVIDENCE: Information for service users was seen in the Service User Guide for the home and in general information seen. As part of the examination of service users’ records, an assessment was seen for a recently admitted resident. This service user said that they had been for a day visit to experience what it might like to live at the home and said “it just felt right”. The actions required of staff to support a service user who has confusion and a tendency to wander were also recorded. Records seen showed that comprehensive personal information had been gathered and recorded. Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 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 and 10 The health and personal care needs of service users are recognised and recorded so that service users can be sure that they are being looked after. EVIDENCE: Four service users’ records were examined. These recorded specific needs in personal and health care needs and were well maintained and up to date. One service user spoken with said that she had the assistance of the community nurse with her diabetic illness. The records showed that the health care of service users had been recorded and the care plan reflected the actions staff needed to take to support individual service users, e.g. what to do if someone prone to fainting was found in a faint. The medication system was examined. Medication is administered from a monitored dosage system provided by a qualified pharmacist. A medication policy and procedure is in place designed to protect residents. Records detailing the medication time and dosage were seen, were signed and were up to date. Storage and disposal of medication was seen and was satisfactory. Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 10 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 and 15 Daily life and social activities offer service users opportunities to live their preferred lifestyle and retain relationships in the wider community. EVIDENCE: Service users spoken with individually and in groups said that they were very happy with their lifestyle at the home. One service user who had been recently admitted said that she had felt that she had been able to make new friends within the house and said “I’m really enjoying my life here”. She commented that she looked forward to the work on the passenger lift being finished, as she had not been able to meet everyone resident at the home, and was looking forward to this. A visiting clergyman was seen. A newsletter the “Peregrine House Gazette” was seen in residents rooms and in the main lounge area of the home. Entertainment is brought into the home on a regular basis in the form of singers, musicians and mobile theatre. The service users are offered motivation classes, bingo, bowls and trips are organised fortnightly using a hired vehicle. A wide choice of meals is on offer and daily routines are flexible to suit individual preferences. A monthly religious service takes place in the lounge and a Catholic priest visits to give holy communion to those service user who request this. All planned entertainment is advertised on the notice Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 11 board and service users are reminded of what is on offer as the time approaches. The installation of a new passenger lift at the home has prevented service users moving easily between the floors of the home. A dining area had been set up on each floor for service users to take their meals rather than come to the ground floor dining room. All service users spoken with said they understood the need for the work and did not mind this temporary arrangement. Several expressed concern for staff employed at the home who needed to bring food up the stairs and clear crockery afterwards. Service users said that they enjoyed the food served at the home and that a choice of food was available. Lunch served looked appetising and nicely presented and staff were attentive to service users’ needs when serving the meal. Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 12 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): Service users are able to make a complaint using information provided by the home. Service users are protected by the awareness of staff of potential abuse. EVIDENCE: A complaints policy and procedure is in place and was examined. People resident at the home are given information on how to complain in the Service User Guide to the home. The procedure includes timescales for investigation and response to any complaint made. Service users spoken with said they had had no occasion to make a complaint, but would speak initially to the registered manager. The complaints record was examined: there had been no complaint since the last inspection. The registered manager has access to the local authority’s protocol on the protection of vulnerable adults. Training for staff on protecting vulnerable adults was seen on notice boards and the registered manager said it was the intention that all staff attend the training. Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 13 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): The people using this service live in a clean and well maintained environment. EVIDENCE: A number of bedrooms, bathrooms and communal areas of the home were seen. All areas were decorated and furnished in keeping with the overall style of the building and it’s layout enables service users choose to have company or not. Those parts of the home seen were uniformly warm and free from unpleasant odours. The home was clean despite building work affecting each of its floors. Records were seen about maintenance of the building, its services and facilities. A requirement was made at the last inspection to fit locks on service users room doors to provide privacy. This issue was discussed with Mrs. O’Sullivan who had made some progress in sourcing appropriate lock fittings. Since the registration category of the home has changed since the last inspection to enable the care of people whose illness may mean that they may be confused or to wander, it is felt that locks must be fitted on room doors. Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 14 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 Staffing levels are at a sufficient level to ensure the needs of service users are met. EVIDENCE: Two months rotas were supplied at inspection and were later analysed. These showed that the number of care staff during the day and overnight complies with the staffing levels set by the previous registration authority and are sufficient to address the needs of service users. Separate kitchen and domestic staff are employed at the home. The registered manager does not under normal circumstances provide direct care. Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The health, safety and welfare of service users is addressed by the arrangements to ensure the building and its systems are maintained in a safe manner. EVIDENCE: Mrs. Alison Bedford is the registered manager of the home. She has completed the Registered Managers Award and is to undertake the NVQ Level 4 in care, which she intends to complete by March 2006. A number of documents were seen relating to the arrangements at the home to ensure that the building and systems in place comply with health and safety legislation. These were:• • • • Gas Safety Certificate dated February 2005 Electrical Installation Certificate dated July 2002 (valid for five years) Checks and service information on the previous passenger lift Fire fighting equipment, emergency lighting and fire detection equipment DS0000007665.V271199.R01.S.doc Version 5.0 Page 16 Peregrine House • checks Fire risk assessment document It was noted that safety checks and servicing records dated back over a considerable time. Advice was given that the current information could be maintained for reference by the manager and owners of the home, and that records which are outdated could be stored separately within the home for reference if necessary. A system is in place to check on the quality standards of the service provided made on an annual basis. Action has been taken to address issues identified as a result of previous inspections. This was demonstrated on this occasion when concern expressed about fire containment during installation of a new passenger lift was dealt with immediately by Mrs. O’Sullivan. Service users spoken with were able to identify how they would deal with any dissatisfaction or complaint and had written information to assist them to do so if they wished. Several service users said that they had no complaints about the care, the food or accommodation provided. The system for handling service users’ money was examined and was recorded and administered in a proper manner. Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 17 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 1 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 18 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 OP24 Regulation 12(4)(a) Requirement Service users’ rooms must be fitted with locks which can allow staff to gain access in case of emergency. Timescale for action 31/03/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Peregrine House DS0000007665.V271199.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 DS0000007665.V271199.R01.S.doc Version 5.0 Page 20 - 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. 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