Inspection on 23/05/06 for Peveril

This inspection was carried out on 23rd May 2006.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Peveril 03/12/08

Peveril 26/06/07

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Peveril Springbrook Close Harmans Cross Wareham Dorset BH20 5HS Lead Inspector Maxine Martin Unannounced Inspection 23rd May 2006 14.45p Peveril DS0000066383.V293537.R01.S.doc Version 5.1 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 Peveril DS0000066383.V293537.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 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. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Peveril Address Springbrook Close Harmans Cross Wareham Dorset BH20 5HS 01929 427996 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) penrose@penrose.f2S.com Penrose Residential Limited Mr Nigel Derek Wills Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Peveril DS0000066383.V293537.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection None new service registered Brief Description of the Service: Peveril is a family run residential home in a small rural village. It is registered to provide care, accommodation and support to two people who have a learning disability. Residents live as part of the family and have access to most of the home. The accommodation is over two floors with one en-suite bedroom being on the ground floor. The upstairs room has it’s own bathroom on the same level. There is a kitchen area with a small dining table and a large lounge with a dining table. There are gardens to the rear of the property, which are accessible and provide opportunity for outside activities. It is also in easy access to the town of Swanage and Corfe where there are a range of community facilities Peveril DS0000066383.V293537.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was undertaken by Maxine Martin and lasted two and half hours. Initially access could not be gained to the property as the residents and staff were out. It formally commenced at 3.30pm and concluded at 6pm. Both Mrs Jane Wills – responsible person and Mr. Nigel Wills – manager were present throughout and supported the inspection process. There are two new residents at Peverill one on a temporary basis; they were joined on the evening of the inspection by the three residents form Penrose (a home owed and managed by the same organisation/individuals). A brief tour of the premises was undertaken, individual files viewed, other relevant documentation inspected. Residents from both homes joined in the inspection process. For the purpose of this report the term residents and service users are interchangeable. What the service does well: What has improved since the last inspection? This was the first inspection since registration and since service users have moved in. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 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 Peveril DS0000066383.V293537.R01.S.doc Version 5.1 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 the following standard(s): 2 Quality in this area is good. The judgement made is using available evidence including a visit to the service Individuals moving into the service have their needs satisfactorily assessed, however written confirmation that the service can meet these needs is required. EVIDENCE: During the inspection daily records and individual care plans were viewed. The organisation has care plans in place, which record all aspects of an individual’s care. It showed evidence service user’ involvement in the completion of the record and the involvement of other relevant agencies. There was also other relevant documentation from agencies to support the service in meeting individual needs. In discussion with the manager it was evident that there had been considerable discussions with appropriate family members relating to the care of the residents. The files contained risk assessments. In discussions with the manager it was identified that the service needs to send a letter to the service user or their representative confirming that, according to the assessment carried out, the service is able to meet the person’s needs. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 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 the following standard(s): 6, 7, 8. Quality in this area is good. The judgement made is using available evidence including a visit to the service. With consideration to the short time that service users had lived at the home service users can be confident that their assessed and changing needs and personal goals are reflected in a plan of care. Informal review, decision making and goal setting also takes place as part of the daily routine, ensuring that service users’ needs are met. Service users are involved in daily life decisions, and are consulted and play an active part in the life of the home. Service users are involved in individual planning and make positive choices about their own lives, which includes risk taking supported by a risk assessment process. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 Page 10 EVIDENCE: From files, daily logs, discussions with the residents and the manager there was clear evidence of plans being changed to address particular needs that had arisen. During the inspection service users were observed making choices about daily life activities, one service user was very active in preparing the evening meal. The residents have only lived at the home for a short period of time, there has not been an opportunity for formal review. However informally on a regular basis they are involved in setting goals and making daily decisions so that their needs can be met. Observed interaction was very positive and there was a homely, friendly atmosphere in the home. Daily logs included statement that individuals wanted to do a particular activity i.e. ‘go for a pub lunch’ and this had then happened. One service users had needed increased support over the last few weeks and this was evidenced in the daily logs and individuals file. When additional outside support had been required all records were completed and actions detailed. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 15, 16, 17 Quality in this area is adequate. The judgement made is using available evidence including a visit to the service. Service users take part in a range of appropriate activities, which supports their individual choice and development. Service users take part in activities in their local community, which develops relationships and supports integration. Service users have close family relationships and are supported to be involved in activities that maintain other friendships and relationships. Service users are respected and play an activity part in the care setting. Individualised meal plans would enhance the healthy diet that service users enjoy. EVIDENCE: Peveril DS0000066383.V293537.R01.S.doc Version 5.1 Page 12 Within the context of a small family care environment the residents are actively involved in daily living activities, both in the home and the community. Both residents have only lived at the home for a short while and are both in a stage of ‘transition’ due to their current needs, therefore judgements made take this into account. Future inspections would need to re-evaluate the situation once formal reviews have taken place and care needs re-assessed. From observation, daily logs and discussions with residents and managers, people feel part of the overall family environment. Daily logs recorded trips to; horse-riding centres, garden centres, public houses, Swanage, gateway club and family contacts. One service users talked about seeing the family’s horses; a trip out with his relative and a range of other activities. As the home is closely linked to Penrose Residential Home, meal planners were seen that are used in both establishments. However this would be an area for the home to develop so that individual choices are reflected in meals prepared. Currently due to staffing and as the residents know each other there are times when events such as meals and other outing activities are shared at either establishment. During this inspection the residents from Penrose were visiting for their evening meal, the interaction observed between the five residents was very relaxed and positive. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this area is good. The judgement made is using available evidence including a visit to the service. Service users are supported in a way that they prefer and is identified in the care plan, so as to meet their needs. Service users physical and emotional needs adequately met by the service. Service users are supported with medication where necessary to ensure their health needs are met. EVIDENCE: In discussion with one resident, they appeared very settled and said they were happy at the home. Relationships with family members are maintained and the open door policy ensures this flexibility. Care plans and daily logs recorded medical needs and actions taken to meet these. One log detailed concerns from the previous day and recorded urgent action taken as well as detailing the outcome. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 Page 14 Medication charts were inspected; the responsible person has recently had help with setting up a more detailed medication record, which is supporting safe medicine handling. Medicines are kept in a locked cabinet. Care plans and daily logs record a range of health professionals involved who have regular contact in supporting the individuals and advising the home. The manager and responsible person, who currently undertake most of the direct care provision, discussed the regular contact they have with a range of support professionals. They also talked about areas they had required support with i.e., ill health, behavioural matters and detailed how appropriate professionals had given advice. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this area is good. The judgement made is using available evidence including a visit to the service. Service users feel valued and that they can express their views openly in this family, caring environment. Service users are protected from abuse and supported to ensure their needs are met. EVIDENCE: Care plans and daily logs recorded individual choice, service users were observed making choices and interacting positively with Mr. And Mrs. Wills. The open door policy and regular contact with relatives and professionals provides a mechanism of monitoring as well as support in the area of the residents needs. From discussions with one resident they were happy and spoke positively of their relationship with the manager. Both Mr. And Mrs Wills have completed training on adult protection and there is a policy in place. There is a complaints policy, which is detailed, in pictorial format as well as words to support access. There had been no complaints since the residents had moved in. Currently both residents manage their own finances with minimal support. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this area is adequate. The judgement made is using available evidence including a visit to the service. Service users live in a homely environment, which supports their emotional needs and affords the opportunity to live in a family care environment. The home environment is generally adequately clean, however shortfall’s in staffing is placing pressure on this area of practice. EVIDENCE: During the visit interaction observed during the preparation of the evening meal was very positive and such that you would expect to see within a family unit. Residents were actively encouraged to take part. Residents appeared very relaxed and freely accessed things they wanted whilst waiting for the meal. Fire records inspected and from observation the home has installed a high level of equipment to ensure the safety of everyone. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 Page 17 Fridge and Freezer temperatures are monitored appropriately. Currently Mr. & Mrs Wills are in the process of trying to employ another full time member of staff for this home. They both provide considerable direct care to the residents of both homes (Peverill and Penrose) they expressed that they have not been able to get everything in place or as organised as at Penrose due to the staff situation. This is affecting the environment as well as the systems that need to be in place in the home. Rooms inspected were of a reasonable standard however due to events that day, daily routines of cleaning up had not been completed. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this area is adequate. The judgement made is using available evidence including a visit to the service. Service users are supported by appropriately trained and skilled staff, which enables their needs to be met. Staffing levels need to increase to enable people’s needs to be fully met. Service users are adequately supported by the home’s recruitment policies and practices. Adequately trained people satisfactorily support service users. EVIDENCE: During the inspection Mr. & Mrs. Wills openly discussed the frustration at not being able to finalise the employment of a prospective member of staff. They are dealing with this on a daily basis. However, this means that the service is stretched between the two homes. No new staff have been appointed since the last inspection however current documentation relating to the possible employment of a new staff member would indicate that appropriate systems and procedures are in place. The interview records of the prospective staff member were seen and other related Peveril DS0000066383.V293537.R01.S.doc Version 5.1 Page 19 documentation, which was all in order. The delay relates to work permits. The experience and qualifications of the individual was appropriate to the needs of the individuals in the home. Advice was given regarding the POVA process, as the home has not previously used this reference system. Mr and Mrs Wills, who are appropriately trained, currently provide most of the care to meet identified needs. Mr. & Mrs. Wills have both completed the registered managers award and have undertaken a range of related training and have many years practical experience in care. From observation they have a very positive relationship with the service users. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42. Quality in this area is good. The judgement made is using available evidence including a visit to the service. Service users benefit from a well run home. Given that this is a recently established home, service users can be confident that their views are listened to and this will be incorporated into review and self-monitoring. The service is progressing in putting in place record keeping systems and policies, which will safeguard service users and currently need to sufficiently protect their confidentiality. Current staffing levels potentially compromise the service in meeting the welfare needs of service users. . Peveril DS0000066383.V293537.R01.S.doc Version 5.1 Page 21 EVIDENCE: Service users choices and views are taken into account not only in the care planning process but also as observed in every day life. Service users appeared to be settled and able to communicate their needs to the manager. As one person is only temporary and one in the very early stages of moving into a care environment this will need to be explored at the next inspection. Very positive interaction was observed between Mr & Mrs Wills and the residents, some of who have very complex communication needs. The daily logs inspected were not signed and due to the recent move into the home, records were not stored securely. The care plans did not have a picture of the residents on them. All these matters were discussed with Mr & Mrs Wills at the inspection who stated they would be rectified urgently. Service users records contain good detail, however procedures are not sufficiently in place at present to ensure they have all the necessary contents detailed in Schedule 3 and are stored confidentially. A recent incident of minimal restraint was discussed and advice given that they needed to submit a Regulation 37. Mrs. Wills stated that they would submit others in the future if required. A Reg. 37 form was sent to them after the inspection for future use. Restraint training has been completed by Mr and Mrs Wills documentation was submitted after the inspection to confirm this. Mr. & Mrs. Wills explained the current difficulty relating to employing a full time member of staff, which would then mean both Peverill and Penrose have sufficient staff to meet identified needs. The ethos of the home to provide a family care environment was evident from observation. There was very positive relationships observed between the service users from Peverill and Penrose. Peveril DS0000066383.V293537.R01.S.doc Version 5.1 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 2 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 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 2 34 x 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 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 2 3 x Peveril DS0000066383.V293537.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 YA2 Regulation 14 (d) Requirement The registered person must confirm in writing that the service is able to meet the identified needs of the service user/s. This procedure needs to be established and retrospective confirmation undertaken. The premises need to be maintained to an appropriate standard. Staffing level’s need to be increased to ensure that residents need’s can be met and that the service compiles with regulations. Records need to be dated, signed and stored confidentially. All items detailed in schedule 3 need to be included. Timescale for action 31/07/06 2 YA30 23 31/07/06 3 YA33 18 (1)(a) 30/08/06 4 YA41 17 (1) (a) (b) 31/07/06 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 Peveril DS0000066383.V293537.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Peveril DS0000066383.V293537.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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