CARE HOMES FOR OLDER PEOPLE
Peregrine House 48/52 Upgang Lane Whitby North Yorkshire YO21 3HZ Lead Inspector
Gill Sample Unannounced Inspection 11:40 23 February 2006
rd 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.V276726.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Peregrine House DS0000007665.V276726.R01.S.doc Version 5.1 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.V276726.R01.S.doc Version 5.1 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. 13th December 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.V276726.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report gives the findings of the second unannounced annual inspection which was made on 23rd February 2006. Because the majority of key standards had been inspected on 13th December 2005, this inspection focussed on those key standards not inspected and the requirements and recommendations made at the last inspection. Some of the premises were inspected including a number of bedrooms, bathrooms and living areas. A range of written records relating to staff were examined. Discussions were held with two individual residents and a group of residents and with one visitor to the home as part of the inspection. Discussions were held with the registered manager and with staff on duty while the inspection was being made. Observation of the meeting at change of staff took place. What the service does well: What has improved since the last inspection?
A new passenger lift has been installed at the home. The registered manager has completed the Registered Manager’s Award and is progressing towards the qualification in care required by the standards. Peregrine House DS0000007665.V276726.R01.S.doc Version 5.1 Page 6 The process of installing suitable locks on residents’ room doors has started and ground floor rooms have new locks in place. The work is to be progressed by the home’s handyman until completed. 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.V276726.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Peregrine House DS0000007665.V276726.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: Peregrine House DS0000007665.V276726.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: Peregrine House DS0000007665.V276726.R01.S.doc Version 5.1 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): None of these standards were assessed on this occasion. EVIDENCE: Peregrine House DS0000007665.V276726.R01.S.doc Version 5.1 Page 11 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): None of these standards were assessed on this occasion. EVIDENCE: Peregrine House DS0000007665.V276726.R01.S.doc Version 5.1 Page 12 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): None of these standards were assessed on this occasion. EVIDENCE: Peregrine House DS0000007665.V276726.R01.S.doc Version 5.1 Page 13 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): 28, 29 and 30 Service users are protected by being cared for by trained and competent staff who are supervised properly. Recruitment and selection procedures are designed to ensure that people who are unsuitable to work with vulnerable adults are not employed in obtaining criminal records disclosures on potential staff. EVIDENCE: There are twenty four members of staff and an additional six staff who are employed to provide relief cover at the home. Six staff have achieved NVQ level 2 in care, and one who has the NVQ 3 qualification in care. Three staff records were examined, one of which was for a recently appointed member of care staff. Records contained written application forms, two written references and records of telephone discussions with referees. The General Social Care Council’s Code of Conduct was signed as received on staff records. Copies of statement of terms and conditions of employment were present on file. Of the three staff files seen, one file had no criminal records disclosure and one had a criminal records disclosure which had been issued for another organisation but prior to the guidelines which prevents the acceptance of a check made outside the employing organisation. The registered manager was aware that a criminal records disclosure is required for each member of staff who has regular contact with service users, but was not aware of the most recent guidance on the protection of vulnerable adults which requires a criminal records disclosure or a POVA First check being carried out prior to the
Peregrine House DS0000007665.V276726.R01.S.doc Version 5.1 Page 14 appointment of new staff. manager. A copy of the guidance was given to the registered Training records for staff were examined. An overall programme of training achieved is maintained to enable the registered manager to identify training needs of the staff group. Staff maintain their own copy of their training and two such examples were seen. Records showed training completed in mandatory health and training topics and specialist training pertinent to the service users resident at the home, such as dementia training. The registered manager and senior staff are also undertaking a distance learning course on dementia based on workbook learning. Peregrine House DS0000007665.V276726.R01.S.doc Version 5.1 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): 38 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: A new passenger lift has been installed at the home so that service users can access all areas of the home. This work was being carried out when the last inspection was made and the registered manager and provider have ensured the safety of service users during the installation and associated building work and have kept the Commission informed throughout the process. The documentation for the new lift has not been issued by the installers, and the registered manager agreed to forward the documents certifying the safety of the lift to the Commission. A check on the gas safety at the home has been made and a Gas Safety Certificate is yet to be issued. A copy of this will also be supplied to the Commission.
Peregrine House DS0000007665.V276726.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Peregrine House DS0000007665.V276726.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 2 Refer to Standard OP28 OP29 Good Practice Recommendations The percentage of staff who are qualified to NVQ Level 2 or equivalent should be achieved and maintained at 50 per cent. The registered manager should check all staff files to ensure that proper criminal records disclosures have been undertaken on all staff in accordance with protection of vulnerable adults guidance. The registered manager should retain copies of the criminal records disclosures in accordance with the written guidance supplied at inspection (3.11. of the document) Peregrine House DS0000007665.V276726.R01.S.doc Version 5.1 Page 18 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
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