Inspection on 12/12/06 for Peterhouse

This inspection was carried out on 12th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Peterhouse 27/11/08

Peterhouse 20/12/05

Peterhouse 14/06/05

Peterhouse 17/02/05

Peterhouse 19/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Peterhouse Church Street Old Town Bexhill On Sea East Sussex TN40 2HF Lead Inspector June Davies Key Unannounced Inspection 12th December 2006 10:00 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 Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Peterhouse Address Church Street Old Town Bexhill On Sea East Sussex TN40 2HF 01424-730809 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) l.crisford@nabs.org.uk NABS Lesley Crisford Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. That only older people may be accommodated That service users accommodated will be aged sixty five (65) years or over on admission That the maximum number of service users to be accommodated will not exceed thirty six (36) That the maximum number of service users in receipt of nursing care must not exceed twenty six (26) That the maximum number of service users receiving residential care must not exceed ten (10) That a maximum number of three (3) service users over the age of fifty five (55) years can be accommodated to receive nursing or residential care. 20th December 2005 Date of last inspection Brief Description of the Service: Peterhouse is a purpose built care home situated in a quiet part of the old town in Bexhill on Sea. It is within a short walking distance of local shops, church and train station. There are several close amenities that include a GP surgery and pharmacy, community centre, public house and a corner shop. The East Wing at Peterhouse is registered to accommodate up to 26 older people who require nursing care and 10 residential places for those requiring only a level of personal care. Accommodation is provided over two floors. Shaft lifts are fitted to assist those residents who have additional mobility needs. A number of sheltered housing flats adjoin the care home with some shared facilities. There is level access to well-maintained communal gardens. Peterhouse is owned by the National Advertising Benevolent Society (NABS), which is a charitable organisation based in London. The charity provides a wide range of support to those who have worked in the advertising and related industries, but opened its services to local people not connected to the industry in 2002. Peterhouse is its only care home. Fees are £560.00 to £850.00 per week. Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on Tuesday 12th December 2006 between 9.30 a.m. and 5.30 p.m. The inspector spoke with the registered manager, head of care, five residents, four members of staff and two visitors to the home. The inspector looked at all documentation kept in the home relating to the key standards inspected and carried out a tour of the home, which included communal areas, residents bedrooms and laundry facilities. Further information was also gained from resident surveys sent out prior to this key inspection. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. What the service does well: What has improved since the last inspection? All but one of the requirements made at the previous inspection had been met, this included improving the administration of medication including reviewing policies and procedures, the provision of food of food has improved and residents have an excellent choice of food for breakfast, lunch, high tea and supper, and the registered manager has published the results of the residents surveys which were sent out in June 2006. Improvements have also been made to the environment of the building which includes new fitted carpets in Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 6 all communal corridors and in some bedrooms, wash basins in some rooms have been moved to provide a larger space for specialist equipment to be used, new curtains in some rooms, one communal bathroom has been made into a wet room, the saniflow toilets in some bedrooms have been replaced and the kitchen has been refitted. 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. Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 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 Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 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): 1, 2 and 3 Each resident is aware of his or her role and responsibilities in the home. Residents move into the home knowing that their needs can be met and that their independence will be maximised and promoted. Quality in this outcome area is good. EVIDENCE: The service user guide is kept under review to include any changes that may have occurred. Each bedroom in the home has a copy of the service user guide, and prospective residents their relatives/representatives are also given a copy of the guide prior to entering the home. The inspector viewed the contracts/statement of terms and conditions of four residents’; these documents are kept in the resident’s personal file. There was also evidence to show that residents are sent a letter each year just prior to the change of fees. For those residents funded by a local authority there is a signed statement of terms and conditions, together with annual letters informing them of a fee change. Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 9 The inspector also viewed the pre-admission assessments of four residents. The home carries out its own pre-admission assessment and there was also evidence in two residents files of care managers pre-admission assessment together with basic care plans, one file had a NHS pre-admission assessment. The homes pre-admission assessment was seen to be comprehensive covering all aspects of care and as outlined in National Minimum Standard 3.3. The home does not offer intermediate care. Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 10 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 Residents know that their personal goals are reflected in their individual care plans and that potential risks are managed. The health needs of the residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication at this home is well managed promoting good health. While staff do their best to ensure that the privacy and dignity of the residents is met, more work needs to be done, to prevent the privacy of the residents being invaded by noise. Quality on this outcome area is good. EVIDENCE: The inspector viewed the care plans of six residents. These care plans were seen to be comprehensive and covered all aspects of physical, personal and social care. All care plans had been signed by residents and or relatives/representatives. Three of these care plans were for residents receiving nursing care and three for residents receiving residential care. Care plans contained evidence of contact details, medication history, mobility, continence assessment, mental and cognitive ability, basic medical history, Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 11 physical needs, diet preferences, including specialised diets, weight charts, sight, hearing and communication assessments, likes and dislikes, personal hygiene requirements, tissue viability etc. The inspector noticed that risk assessments contained within the care plans were informative giving the care staff good guidelines as to how the risk could be kept to a minimum. Each care plan contained evidence of monthly reviews. From the care plans the inspector was able to evidence that residents’ personal hygiene needs are met, while staff try to maintain residents independence in this area. Care staff regularly check the tissue viability of those residents who receive residential care and if there is any cause for concern, staff will contact a G.P. or district nurse. For those residents who receive nursing care the RGN’s employed by the home will deal with any concerns regarding pressure areas. One RGN has received specialised tissue viability training, and has a resource folder, which gives dressing protocols with first and second choices of dressing to be applied. The home also has access to a continence nurse who will assess residents for continence aids. Two residents in the home have regular visits from a community psychiatric nurse. Access to a psychiatrist is via referral from the G.P. The residents both in residential care and nursing care have access to the G.P. of their choice. All visits from the multi disciplinary team are recorded in the residents individual care plans. The inspector also noted that were relevant residents have visits from the Parkinson nurse, Motor Neurone Specialist, Stroke Rehabilitation Team, Chiropodist, Dentists and all these visits are appropriately recorded together with any requests for specialised care. The home uses Boots the Chemists, monthly monitored dosage system, and had recently had a Boots pharmacy inspection. The medication policy and procedure needs to be reviewed to include the administration of homely remedies. All other policies and procedures relating to medication had been reviewed this year. There was a list of staff qualified to administer medication together with the signatures and initials. The whole home comes under nursing status for the disposal of medication, and therefore the home has a contract with a company who will dispose of any unused medication. The inspector viewed the returns book and noted that it was kept up to date by the RGN’s working in the home. The RGN’s together with two senior carers, who have received administration of medication training, have responsibility for the administration of medication within the home. For those residents who are self-medicating a risk assessment has been completed and is kept on their care plan. The inspector carried out audit of medication and found that MAR sheets were all completed correctly. The home does have some residents who take controlled drugs. This medication is double locked into a C.D. cupboard, and the controlled drugs register had been completed correctly by two members of staff and numbers corresponded with the drugs in the C.D. cupboard. In general the staff that work in the home respect the residents’ privacy and dignity. Residents are able to have visits from G.P.’s and other professionals Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 12 in the privacy of their own bedrooms. The inspector witnessed that staff knocked on resident’s bedrooms doors prior to entering. The interaction between residents’ and staff was friendly and respectful, with staff calling residents by their preferred name. There was one area where the privacy of the residents is infringed, while the inspector observed this at the time of the visit, a visitor and a resident also brought it to the inspector’s attention, they said that a television belonging to a resident was often played too loudly and could be clearly heard from other residents’ bedrooms. Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 13 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 Activities and links with the community are good and support and enrich the residents’ social lives. The meals in this home are good offering both choice and variety and catering for special diets. Quality in this outcome area is good. EVIDENCE: The residents’ told the inspector that the routine of daily living are flexible, and that they are able to have meals in their rooms if they wish to, they also have a choice of two dining rooms. The inspector also evidenced this on the day of visit. Residents’ also told the inspector that there are a range of activities they can take part in if they wish to. Evidence was also available on the day of the visit in the form of posters on notice boards to inform the residents of what activities were on offer for each day of the week. On the afternoon of the visit many of the residents went to the function room in the home to watch a pantomime. There are also social club functions, regular outing to the shops and supermarkets. The home also has its own drinks bar in a communal television lounge, which serves alcoholic and non-alcoholic drinks. The inspector also noted that a programme was clearly displayed giving residents information regarding Christmas activities. Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 14 Residents are able to have visitor at any time, and on the day of the inspection many visitors were present at the residents’ pantomime. Coffee mornings are also arranged for the friends of the home, and residents are able to participate in these mornings if they wish to. Residents told the inspector that they are able to entertain relatives and friends in their own bedrooms if they wish to. The manager does not act as appointee for any of the residents finances. Relatives or representatives deal with personal finances of the residents. During a tour of the premises the inspector noted that all bedrooms were personalised to reflect the residents’ own personalities. Small items of furniture, pictures, ornaments and photographs had been brought into the home from the residents own homes. The registered manager and head of care confirmed that residents are able to have access to their own personal records as and when requested. The inspector was shown a four-week rotating menu, which is also changed seasonally. Residents are offered a wide choice and variety of food, for breakfast, lunch, high tea and supper. From the menus and discussion, and information given by the residents, the food in the home is well cooked, well presented and nutritious. Some of the residents need to have soft diets, and each item of food is liquidised or cut up separately to ensure it is presented attractively and is appealing. The inspector observed that mealtimes are unhurried, and those residents who wish to take longer over their meals are able to do so. Some of the residents do need help to feed and staff do this in a caring and sensitive manner Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 15 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): 16 and 18 Residents know their complaints will be listened to and acted on. Staff have good knowledge and understanding of adult protection issues, which protects the residents from abuse. Quality in this outcome area is good. EVIDENCE: The inspector viewed the complaints procedure that had been reviewed this year. This policy and procedure is also included in the service user guide and prominently displayed in the main entrance hall. Since the last inspection the home has received nine complaints, all the complaints had been appropriately recorded, investigated and letters sent to the complainants within the timescale stipulated in the complaints policy and procedure. Four complaints had been substantiated, two were partially substantiated and three were unsubstantiated. Both resident surveys and residents spoken to during the course of the inspection stated that they would know how to complain, and they also verified that the complaints policy and procedure was included in the service user guide. Since the last inspection there has been one adult protection raised this has been investigated and resolved by the adult protection team, but a POVA referral is still ongoing. The inspector viewed the adult protection policy and procedure; whistle blowing policy and procedure, management of resident’s monies and valuables policy and procedure and aggression towards staff policy Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 16 and procedure all of which had been reviewed this year. Staff have copies of these policies and procedures given to them at the start of their employment. All staff have received adult protection training. Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 17 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): 19 and 26 The standard of the environment within the home is good providing the residents with an attractive and homely place to live. Both the Manager and staff have good knowledge of infection control systems, which helps to protect residents from cross infection. Quality in this outcome area is good. EVIDENCE: The inspector carried out a tour of the home during this inspection and found the home to be well maintained and clean with no offensive odours. The registered providers have an annual development plan for the home that was published in July 2006. Since the last inspection, a wet room facility has been provided from a domestic bathroom. Some of the saniflow toilets have been replaced. Curtains have been replaced in some of the bedrooms and communal rooms. The washbasins in some of the bedrooms have been moved, to allow more space for specialist equipment to be used. Some of the bedrooms in the home have been refurbished and re-carpeted. New carpets have been fitted to all communal corridors. The kitchen has been totally Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 18 refurbished. The gardens surrounding the home are safe, well maintained and tended, and provide excellent facilities for residents to sit and enjoy the open air. The inspector was shown letters from the local fire safety officer and the environmental health officer, to show that the home meets standards required. The premises were clean and hygienic on the day of the visit, and there were no offensive odours. The inspector noted that toilets used by members of staff displayed universal hand washing notices. The laundry was sited away from areas were food is prepared and handled. The inspector noted that the laundry was well ordered, clean and tidy. Red alginate bags are used for laundry that is soiled. The industrial washing machine has a sluicing and disinfecting facility to ensure there is no risk of cross infection. The sluice room, which contained a sluicing disinfector, was clean and tidy, and covered skips containing a yellow bag for the collection of clinical waste were also sited in the sluice room, and hand washing facilities were available for staff. Staff are supplied with disposable gloves and plastic aprons, and the dispensers for this protective clothing were sited in appropriate places throughout the home. The inspector did note that two communal toilets had waste bins without lids attached and the inspector will make a recommendation that all waste bins are supplied with lids to reduce the risk of cross infection. Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 19 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, 28, 29 and 30 Staff morale is high resulting in an enthusiastic workforce that works positively with the residents’ to improve their whole quality of life. Staff are multi skilled ensuring good quality care and support. Recruitment policies are fairly good, but some further work needs to be done to ensure that staff are appropriately vetted. Quality in this outcome area is good. EVIDENCE: The inspector viewed the staff rotas on the day of inspection and had also been provided with four weeks rotas enclosed within the pre-inspection questionnaire. All rotas showed that there were sufficient nursing and care staff on duty both on the day of the inspection and at other times to meet the needs of the residents. Care staff were able to confirm that they do not feel rushed, but on some occasions when residents are ill they are busy. Nominated staff are rostered on duty specifically for residents activities to take place. The residents who spoke with the inspector said that there were sufficient staff on duty at all times, and that staff were prompt when answering their call bells. The home employs sufficient ancillary staff to ensure that the home is kept clean at all times. At the present time 45 of the care staff have NVQ level 2 or above, with four more care staff in the process of completing their NVQ qualification, which will then give 65 of care staff with NVQ qualification. While the home has their Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 20 own bank of staff, occasionally there is the need to cover some care shifts with agency staff some that have a NVQ qualification. The inspector viewed six staff personnel files (1 Registered Nurse, 3 carers, 1 domestic and 1 chef) all files had an application form, at least two written references, CRB checks, POVA first checks, none of the staff applications had a complete history of employment. The inspector will make a requirement that in future all application forms contain a full employment history, with any gaps in employment being investigated. The manager confirmed that all new staff are given a copy of the GSCC code of conduct. The home does employ four volunteers, three of these volunteers are part of the Management Board, and another volunteer assists with outings and the friends committee, all have been CRB checked. All staff have completed Adult Protection training, Health and Safety, Diversity, Food hygiene, Moving and Handling, Infection Control, Fire Training, fifteen staff have appointed first aid training, and 24 staff have completed one day first aid training. There is always an appointed first aider on each shift. Four RGN staff are also fire wardens. RGN staff have completed job related training in wound care, catheter care, bowel care, continence care, anxiety and depression, Parkinson’s disease, epilepsy and multiple sclerosis. One RGN is also the appointed trainer for the home she has an A1 assessor’s qualification and is qualified to training all mandatory training to the staff. A senior carer who has her A1 Assessors Award has also attained an additional qualification/training to teach moving and handling. This information was evidenced via discussion with the Registered Manager, Head of Care, staff spoken to during the visit, and the staff-training matrix. All new members of staff receive induction training and foundation training within the first six months of their employment. Induction training is to Skills for Care standards (supplied by a training company). All new staff are also given a staff handbook and a pack of relevant policies and procedures used in the home at the beginning of their employment. Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 21 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): Standards 31, 33, 35 and 38 The manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. Quality assurance needs to be monitored more thoroughly to ensure that the residents receive the best quality of care. Health and safety practices in the home are good ensuring a safe environment for both residents and staff. Quality in this outcome area is good. EVIDENCE: The registered manager is a registered nurse and health visitor and holds a degree in community health studies and has now has completed her Registered Managers Award, two other senior managers in the home have also gained the registered manager award. All the staff and residents spoke highly of the Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 22 registered manager. There are clear lines of accountability in the home, and the registered manager receives support from the care manager, resource manager and administrative staff. A survey was carried out in June 2006 from residents living in the home and a feedback was completed from these surveys. To date no quality assurance surveys have been sent to relatives/representatives, stakeholders and staff. The registered manager told the inspector that she regularly quality monitors the standards of care, cleaning, cooking, administration of medication, care plans including reviews, but does not record these. The inspector was shown that regular recorded risk assessments are carried out for health and safety issues both internally and externally. The inspector is making a requirement that quality assurance within the home is further developed. The registered manager oversees the management of personal allowances for 8 residents in the home, each of these residents has a cash sheet with their name on it, and these sheets record monies received and monies being spent. When money is spent an invoice is raised with an accurate description of the purchase, and a receipt is attached to the invoice. Money coming in and going out always has two signatures, admin and management. Personal allowances are checked monthly to ensure that they are correct. All personal allowances are kept securely within the home. The inspector viewed health and safety policies and procedures and noted that all these policies and procedures had been reviewed between January and July 2006. All staff with exception of the newest recruits have undertaken moving and handling, fire safety, first aid, food hygiene, and infection control training. The inspector was also shown that all equipment used in the home had current service certificates. Every window in the home is fitted with window restrictors. The inspector was shown the HSE accident book and noted that all accidents are appropriately recorded and where necessary the appropriate authorities are informed. All staff receive health and safety induction and the inspector was shown evidence of this in staff personnel files, and this was also confirmed by members of staff spoken to on the day of the inspection. Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 23 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 24 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 OP10 Regulation 16(2)(m) Requirement That the volume of personal televisions is kept at an acceptable level, to protect the privacy of other residents in the home. Previous requirement not met 20/12/05 The staff application form must give a full employment history and any gaps in employment must be fully investigated. The registered person shall establish a system for evaluating the quality of the services provided at the care home by ensuring that recorded monitoring takes place for all systems in the home. Timescale for action 01/02/07 2. OP29 Sched. 2 (6) 24(1) 01/02/07 3. OP33 20/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Peterhouse Refer to Good Practice Recommendations DS0000014025.V305001.R01.S.doc Version 5.2 Page 25 1. 2. Standard OP9 OP26 The policy and procedure for homely remedies is reviewed and updated. All communal waste bins should have fitted lids to prevent the risk of cross infection. Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Peterhouse DS0000014025.V305001.R01.S.doc Version 5.2 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!