Inspection on 10/06/05 for Peterhouse

This inspection was carried out on 10th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Peterhouse 16/11/07

Peterhouse 16/11/06

Peterhouse 20/12/05

Peterhouse 17/08/04

Peterhouse 14/04/04

Similar services:

Coopers Mill Ltd

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Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Peterhouse Sneating Hall Sneating Hall Lane Kirby le Soken CO13 0EW Lead Inspector Neal Cranmer Unannounced 10 June 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Peterhouse Address Sneating Hall Sneating Hall Lane Kirby le Soken CO13 0EW 01255 861241 01255 861241 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) Reverend Graham Beresford Edwards Reverend Graham Beresford Edwards Care Home 11 Category(ies) of LD learning disability (11) registration, with number PD physical disability (11) of places Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The home accommodates eleven people with learning disabilities who may also have physical disabilities. Date of last inspection 17/08/2004 Brief Description of the Service: The home is situated in a semi-rural location, offering extensive outdoor space. The home benefits from having its own occupational therapy suite situated in the courtyard from the main house. The home provides accommodation on two levels. A large communal lounge with access to extensive grounds is available. Bathrooms and toilets have been adapted to meet the needs of service users who require the use of wheelchairs. The home provides transport to facilitate the accessing of local community based activities. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 10th June 2005, lasting 5.5 hours. The inspection process included: discussions with two service users, the deputy manager and two staff. Tour of the premises included observations of two service users’ bedrooms, bathing and toilet facilities, as well as communal and garden areas. During the course of the inspection a range of documentary evidence was sampled, most of which was seen to be in order. Twenty-five standards were inspected, three of which were identified as being minor shortfalls. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that staff receive formal supervision every six to eight weeks. The home needs to review its staffing levels periodically, using the recommended formula, to ensure its staffing levels are adequate to meet the needs of the service users. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 6 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. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 5 The Statement of Purpose and Service Users Guide were both very informative. Service users’ Contracts of Residency were comprehensively detailed and laid out clearly. EVIDENCE: Both the home’s Statement of Purpose and Service Users Guide were comprehensively detailed documents. The Service Users Guide was written in plain English and pictures were used to enhance the messages being given. Two service users’ contracts of tenancy were sampled. Both were presented in plain English and were explicit in terms of what and was not provided by the home, and both were seen to have been signed by the registered manager and the service users’ representative. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8. Service users are involved/participate in the day to day running of the home. EVIDENCE: During the course of the inspection service users were witnessed being involved in a range of daily living tasks, e.g. cooking, washing-up, collecting dirty laundry and general household cleaning. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 13, 15, 16 and 17. The home is proactive in supporting service users’ personal development. Service users are supported by the home to access the community whenever possible. The home supports service users well to maintain links with family and friends. Meals provided by the home are of a good standard. EVIDENCE: Service users are supported by the home to fulfil their spiritual needs. The manager spoke of two service users attending the local church every Sunday. In addition, services are held at the home on a regular basis. Staff spoke of service users being supported to access the local community for meals out, trips to local garden centres and attendance of a variety of local clubs. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 11 Staff spoken with during the course of the inspection spoke of the home having an open door policy on the receiving of visitors. One service user spoken with spoke of their plan to visit their father later in the year, and the fact that they were going to be supported by the registered manager to make the trip to see their parent. At the start of the inspection service users were in the dinning room having their breakfast, supported by staff, and discussion with service users indicated that they had enjoyed their breakfast of cereal and toast. The meal was observed to be taken in a homely congenial setting, which was relaxed and unhurried. Further discussion with a service user later in the day indicated that the meals are always nice and plentiful. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19. Service users’ healthcare needs were well met and records pertaining to appointments were well documented. EVIDENCE: Discussion with the deputy manager indicated that whenever service users attend healthcare appointments staff complete reports. This information is then transferred onto a computer database and the paper copy is stored in a locked filing cabinet. All service users are registered with a local General Practitioner. On the day of the inspection two service users were witnessed being supported to attend dental appointments. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home’s Complaint Procedure was comprehensively detailed. The home’s Adult Protection was seen to be robust. EVIDENCE: The home has a Complaints Procedure, which meets with the requirements of Standard 22. Staff spoke of their awareness of the procedure. The manager spoke of copies of the procedure being made available in all new starters’ packs. The home’s Adult Protection Procedure was seen to be robust. Staff have all received copies of the guidelines and received in-house training on the subject. The manager was advised to consider seeking more formal training for staff on this subject. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 28, 29 and 30. The home provides a comfortable safe environment for service users. Service users’ bedrooms seen were deemed to meet their individual needs and lifestyles. Service users’ rooms were well equipped to meet with their needs. Shared space at the home was seen to be more than adequate and was accessible to all service users. The home provides a range of aids and adaptations to enable service users to maximise their independance. The home maintains an environment that is clean and tidy. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 15 EVIDENCE: A tour of the premises evidenced that they were safe and accessible to all service users. Toilet and bathing facilities were good. On the day of the inspection the home was bright and cheery. Those rooms sampled during the course of the inspection were seen to meet with individual needs. Three service users’ rooms were visited during the course of the inspection and were seen to contain all of the furniture required under Standard 26. The home has extensive indoor communal space, to which service users were seen to have full access In addition, the home also has extensive outdoor gardens and grounds. The home also provides its own occupational therapy room which is located within the grounds adjacent to the main house. The home provides a range of aids and adaptations to assist service users in the maximising of their independence. For example: 1. 2. 3. 4. Hoists Bathing aids Wheelchair access to shower rooms Hand rails. The home’s laundry facility is sited across the courtyard away from the main house. Areas where food preparation takes place were seen to be adequate to meet the needs of the service users. On the day of the inspection the home was seen to be clean and tidy and free from any offensive odours. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 and 36. Service users are supported by a team of staff who are competent and appropriately qualified. The service users are supported by an effective staff team. The home’s recruitment procedures were seen to be in order. Staff have received training relevant to the needs of the service users. Staff benefit from formal supervision, although this needs providing on a more regular basis. EVIDENCE: The home employs 13 care staff, of which 7 have NVQ level 2 or better. Staff were seen to be accessible, approachable and comfortable in the presence of service users. The home does not employ staff under the age of 18. The home has yet to review its staffing levels, using the recommended guidance. Three staff files were sampled and no omissions were noted in relation to Schedule 2 of the Care Homes Regulations. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 17 Discussion with the deputy manager and staff indicated that staff have recently received training in the following areas: 1. 2. 3. 4. 5. 6. Epilepsy awareness Administration of Rectal Diazepam Handling medications Makaton training (stage 1) Train the trainers (Manual Handling) Food hygiene (on-going). Discussion with staff and the deputy manager indicated that staff receive formal supervision every three months. The manager was reminded of the need for staff to receive formal supervision every six to eight weeks. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 and 43. Both the registered manager and the deputy manager have significant experience in managing care services. Observation would suggest that the management approach at the home is open and inclusive. The home has yet to provide a business plan for the service. EVIDENCE: Both the registered manager and the deputy manager are registered for the Registered Managers Award. Both have considerable experience of working in the care sector. Discussion with staff indicated that they find the deputy manager extremely accessible and approachable regarding any issues they may have. There was a sense prevailing that the registered manager/deputy manager both communicate a clear sense of direction and leadership. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 19 No concerns were noted in relation to the home’s ongoing financial viability. The home’s certificate of public liability was seen to be current. The home has yet to develop a business plan for the home which is available for inspection. Peterhouse I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x 3 3 3 Standard No 11 12 13 14 15 16 17 3 x 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 2 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Peterhouse Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x x 2 I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 YA 33 Regulation 18 Requirement The registered person must review staffing levels periodically to ensure that appropriately competent and experienced persons are working at the care home, in such numbers as are appropriate for the health and welfare of service users. This is a repeat requirement. The registered person must ensure that staff receive formal supervision at the frequency required. The registered person must maintain a business plan for the service, which is available to the Commission for inspection. Timescale for action End of September 2005 2. YA 36 18 End of September 2005 End of September 2005. 3. YA 43 25 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 YA 23 Good Practice Recommendations It is strongly recommended that the registered person arrange for the provision of formal training in the protection of vulnerable adults. I56-I05 S17909 Peterhouse V220398 100604 Stage 4.doc Version 1.30 Page 22 Peterhouse Commission for Social Care Inspection 1st Floor Fairfax House Causton Road Colchester CO1 1RJ 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. 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