Inspection on 16/11/07 for Peterhouse

This inspection was carried out on 16th November 2007.

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

Peterhouse 16/11/06

Peterhouse 20/12/05

Peterhouse 10/06/05

Peterhouse 17/08/04

Peterhouse 14/04/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

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 Essex CO13 0EW Lead Inspector Neal Cranmer Unannounced Inspection 16th November 2007 09:00 Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 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 DS0000017909.V355039.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Peterhouse Address Sneating Hall Sneating Hall Lane Kirby Le Soken Essex CO13 0EW 01255 861241 01255 861241 sneating@btinternet.co.uk 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) Reverend Graham Beresford Edwards Reverend Graham Beresford Edwards Care Home 11 Category(ies) of Learning disability (11), Physical disability (11) registration, with number of places Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home accommodates eleven people with learning disabilities who may also have physical disabilities. 16th November 2006 Date of last inspection 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. Accommodation is provided 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. Fees for residing at the home range between £727.44 to £1050.95 per week, there are no additional charges made by the home. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which took place over one day in November 2007, lasting 5.5 hours, and which included observation and discussion with service users, four members of the staff team as well as the registered manager/provider. During the course of the inspection process a range of documentary evidence was sampled, this included the home’s AQAA (Annual Quality Assurance Assessment). The information included in the annual quality assurance form which had been submitted to the Commission for Social Care Inspection, was also used in compiling the inspection report. This form gives homes the opportunity of recording what they do well, what they could do better, and what has improved in the previous twelve months as well as future plans for improving the service. In addition to the above, a tour of the premises was undertaken which included viewing of service users’ rooms, communal areas and gardens. The inspector was invited to join the service users for lunch, and thanks them, the cook, staff and the management for their hospitality. What the service does well: What has improved since the last inspection? Evidence indicated that service users are being provided with a diet that is wholesome, varied and nutritious. Provision had been made to ensure that the home was being kept in a state of good repair, both internally and externally. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 6 Discussion with four members of the staff team indicated that professional relationships within the home had improved and that any concerns raised were dealt with appropriately. The tour of the premises undertaken evidenced that the home was free of any unpleasant odours. 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. The summary of this inspection report can be made available in other formats on request. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users can expect their needs to be assessed prior to admission to the home. EVIDENCE: The home has not had any new admissions for a number of years. However from looking at a sample of completed assessments it was evidenced that the assessment format used covered the following areas: social history, interests, medical history, medication in use, method of communication and family and social contact. The information gathered during this assessment process was then used as the basis for formulating the service user’s initial plan of care. The home’s Annual Quality Assurance Assessment indicated that prospective service users are expected to make at least one visit to the home to gain an initial impression, and would then spend an agreed number of separate visits, including an overnight stay. Admission to the home would be on a six-month trial basis, during which a review would be undertaken by the placing authority to ensure the placement was suitable. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs and personal goals are adequately reflected in their plans of care, and they are supported to make decisions about their everyday lives, and to take risks, with assistance as required. EVIDENCE: Three service users’ care plans were sampled, all of which contained detailed plans, identifying care need objectives, and clear guidance to staff as to how service users needed to be supported to meet the identified objective. Daily records supported each care plans, and all three care plans contained evidence of being regularly reviewed. All reviews seen indicated that service users were always in attendance at their reviews. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 10 All of the service users living in the home have very complex needs, with only one service user being able to make any informed choice about their everyday live, however staff were seen and heard trying to enable all of the service users to make some choices however limited these might have been. At the time of the inspection there were no advocacy service involved with service users in the home, however the contact details of local advocacy services were displayed on the notice board in the dining room. All three of the care plans sampled contained evidence of risk assessments having been undertaken. The assessments included the nature of the risk, the level of the risk to both the service users and others, and the measures that were in place to minimise the identified risk. Risk assessments in place covered support with mobility, outings into the community, mealtimes, medication and fire safety. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect to be supported to take part in age appropriate activities that are community based, and are supported to maintain links with their families and friends. The daily routines of the home are flexible and enabling and help to promote independence. Service users can expect to be provided with a diet that is healthy and wholesome. EVIDENCE: As mentioned previously the needs of many of the service users are complex, however discussion with a service user and a number of the staff indicated that service users access the community in a number of different ways, for example: trips out shopping, going for meals out, occasional trips to the cinema, going to the local pub, visits to the local leisure centre, and Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 12 attendance at places of worship. Weekly activity records are now kept. From the sample seen there was evidence that the range of activities included: Shopping, outing to local pier, trip to local public house, attendance at parish lunches, and attending a 60s disco. One resident has a part-time paid job working one day a week on a local farm, which during discussion they said they still enjoyed doing. Three vehicles are available to enable service users to access the local community and the amenities provided. There is an open door policy on the receiving of visitors, and key workers actively support service users to maintain links with their families and friends, through the sending of cards and letters. One service user spoken with spoke of regularly going home to visit their parent. The Annual Quality Assurance Assessment indicates that service users are free to receive visitors at any time they wish, and that meals maybe provided to visitors without charge. Observation of residents during the course of the inspection evidenced that they have free access to all areas of the home. Written evidence supported this observation, although it was stated that some restrictions might be in place where service users required extra support or supervision. Where this was the case, then it was recorded as an infringement of rights. Three meals are provided daily i.e. breakfast, lunch and tea. Usually lunch provides a hot meal each day. A three weekly rotational menu was in place, and was seen to be varied and nutritious, and provided evidence of a choice being available. The home’s stock cupboards were sampled and included a good range of provisions. Discussion with the home’s cook was positive; with them feeling that they had all of the necessary resources to enable them to carry out their role effectively. The inspector was invited to join the service users for lunch, and was therefore able to observe the lunchtime meal, which was unhurried; service users requiring support from staff were appropriately assisted, and staff were seen to have their meals with the service users. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect their personal care needs to be met in a way that they require and prefer. Service users can expect their health care needs to be well met, and medication procedures safe and well maintained. EVIDENCE: All service users have key workers, and those spoken with were aware of who their key worker was. They also spoke of having a very good rapport with their key worker. A service user spoke of being free to choose when they went to bed, and of having some degree of choice about when they wished to get up, dependant on what they were doing that day. From observation on the day of the inspection there was evidence of staff supporting service users in a manner that respected their dignity and ensured their privacy. Staff were seen knocking on doors before entering, and interactions seen and heard were polite and respectful of the individual. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 14 All of the service users are registered with a General practitioner, and evidence was seen in records of service users being supported to access other local generic healthcare professionals including: opticians, dentists and chiropodists. The home’s medication practice was sampled. Medication is dispensed by a combination of a Measured Dosage System (MDS) and individually named containers. All staff who are involved in the administration of medicines have been trained. The home does not maintain any controlled medicines, and records of medications administered were all in order, with no evidence of any errors or omissions. Medicines that require discarding are returned to the pharmacy via a medicines return book. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect to be protected by the home’s policies and procedures for dealing with complaints and adult protection issues. EVIDENCE: There is a complaints policy, which clearly lays out the actions to be followed in the event of a complaint being made about the home. Since the last inspection one complaint has been made. This complaint was appropriately investigated, involving all of the appropriate agencies, and was unsubstantiated. All members of staff are provided with a copy of the home’s complaints policy at the time of their induction, and discussion with staff indicated that they were aware of how to action a complaint or concern. The home maintains a log of complaints received. The home’s complaints policy was last reviewed in July 2007. The adult protection policy is also robust, and clearly lays out the actions to be followed in the event of a suspected incident of abuse having taken place. All staff have received training in adult protection, either from external sources or by in-house training using the appropriate training pack. The adult protection policy was supported by a range of supporting policies including Whistle blowing, infringement of rights. The adult protection policy was also last reviewed in July 2007. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported in an environment that is homely, comfortable and safe, and is kept free of any unpleasant smells or odours. EVIDENCE: During the course of the inspection a tour of the premises was undertaken, which included viewing of service users rooms, bathing and toileting facilities, as well as communal areas. Overall the premises were fit for their stated purpose, being comfortable, bright, cheery, clean and free from any unpleasant odours. Furnishings and fittings were domestic in nature, and were in keeping with the age of the property, the property itself was well maintained and in a state of generally good décor, since the previous inspection of the home, replacement flooring had been fitted in the downstairs hallway, and a programme of general maintenance and redecoration had been commenced. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 17 The home is equipped with adequate bathing and toilet facilities for the number of service users in residence, and these were seen to be in positions that are convenient to the needs of the service users. Bathrooms were accessible to those service users who required wheelchair access. The home’s laundry facility is situated in an outbuilding across the courtyard from the main house, and was equipped with industrial style washing machines and tumble dryers; the washing machine was equipped with a sluicing cycle. Hand-washing facilities were available, and cleaning products stored in the laundry room were kept in a locked cupboard. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 18 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 33, and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a team of staff, who are knowledgeable about their needs, and who have received an appropriate level of training. Service users can further expect to be protected by the home’s recruitment processes. EVIDENCE: Seventeen care staff are employed and of those seven hold National Vocational Qualifications (NVQ) at level 2, with a further 3 being in the process of undertaking the award, in addition to these seven qualified staff a further two are qualified at level 3, with one other qualified at level 4. Sampling of the home’s visitor’s book evidenced N.V.Q assessors visiting the home. The home does not employ any staff under the age of eighteen, and all staff providing care of an intimate nature are all aged over twenty-one. Discussion with the registered manager and staff indicated that the turnover of staff at the home is low, and the home does not use agency staff, preferring instead to cover sickness and other absences through its own staff. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 19 Observation of interactions seen between staff and service users indicated that staff were comfortable and at ease in the presence of the service users, and that they were committed and motivated. The recruitment process was inspected through the viewing of three staffs recruitment records, all three contained evidence of application forms, written references, criminal record checks, induction, supervision, as well as evidence of training and development. Training records were sampled, and evidence a good level of training being provided, both from external sources as well as in-house training, external training included: N.V.Q level 2, adult protection, medication administration, appointed persons first aid, food hygiene, moving and handling and Makaton. Internal in-house training included: adult protection, induction, and Makaton. Discussion with staff evidenced that team meetings are held weekly, from which minutes were disseminated. During these meetings policies and procedures were discussed alongside any relevant practice issues. Staff spoke of where possible being given opportunities to provide input into the review process of policies. Since the last inspection a number of new policies have been introduced into the home, and all other policies have been reviewed. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 20 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can expect to be cared for and their opinions about the service listened to by a staff team who are well supported by a manager who has good leadership skills. Service users can expect to be safeguarded by the home’s safe working practices. EVIDENCE: The registered manager is qualified at N.V.Q level 4 in management, and is awaiting verification of their level 4 award in care. The manager does have significant previous experience in care, and is also the registered manager for the home’s sister home. Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 21 Discussion with staff indicated that the management approach of the home is open and transparent, and that the manager provides them with a clear sense of leadership and direction. The home has in place a comprehensive process for reviewing the quality of its service provision, which ensures that it seeks the views of the following interested stakeholders: service users and or their representatives, parents, visiting professionals and church groups. Any comments made as part of this process are considered, appreciated and responded to. In addition to the annual review process weekly staff meeting are held, where decisions are made through consultation. Comments made by staff suggested that overall there was now a much better feeling of trust, and as mentioned previously openness. The home’s safe working practices were good, and sampling of the following safety certificates found them to be in order: Portable appliances, COSHH assessments, record of weekly hot water temperature checks, record of visits by fire officer, record of fire alarm tests, record of emergency lighting tests, record of fire instructions/drills, record of spot checks on vehicles, and electrical installation certificate Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 22 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations Peterhouse DS0000017909.V355039.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000017909.V355039.R01.S.doc Version 5.2 Page 25 - 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!