Inspection on 13/08/08 for The Peele

This inspection was carried out on 13th August 2008.

CSCI found this care home to be providing an Good service.

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

The Peele 29/08/07

The Peele 09/05/07

The Peele 30/01/07

The Peele 01/06/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 06/12/2008.

CARE HOMES FOR OLDER PEOPLE The Peele Walney Road Benchill Wythenshawe Manchester M22 9TP Lead Inspector John Oliver Unannounced Inspection 13 August 2008 09:30 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 The Peele DS0000066003.V364667.R02.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. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Peele Address Walney Road Benchill Wythenshawe Manchester M22 9TP 0161 490 8057 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) Inspirit Care Limited Care Home 108 Category(ies) of Old age, not falling within any other category registration, with number (108), Physical disability (12) of places The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can accommodate a maximum of 108 service users. Up to 108 service users may require care by reason of old age. A maximum of twelve (12) beds on a specified unit can be used for Intermediate Nursing Care for service users who are 50 years and over. Of these twelve (12) beds, two may be used to accommodate people who are over 18 years of age. 29th August 2007 Date of last inspection Brief Description of the Service: The Peele is a purpose built care home providing personal care for a maximum of one hundred and eight older people. The home was registered on 8th February 2006. Although this is a large home, the emphasis is on providing group living. The home is divided into three wings on three levels. Each level accommodates three units, making a total of nine units, each of which provides accommodation for between 11 and 13 residents. Each unit has an individual shared living and activity space. All bedrooms lead off from the communal area. Units on the ground floor benefit from direct access into small cottage gardens, whilst the first and second floors lead out onto balcony areas. The ground floor has a large foyer area, which includes a reception area, and a lounge/sitting area with comfortable seating. The kitchens for the whole building are accommodated on the ground floor. The first and second floors provide additional facilities. This includes a library, which overlooks the front gardens and provides large windows which allow light into the building. Furnishing and fittings are of a high standard, and this room provides a pleasant multifunctional area for residents and their families to use. There is also a large social room, which is used for staff training and there are plans to fit it out as a cinema. The home is situated in the Wythenshawe area of Manchester, within easy reach of shops and community amenities. There are secure gardens around the building, providing pleasant outdoor facilities and safe walkways for residents to enjoy in the warmer months. Beyond the garden areas there is parking for a large number of cars. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 5 The fees set for 96 of the beds in the home are between £384:44 to £525.00; the Primary Care Trust funds the remaining 12 beds. Additional charges are made for hairdressing, newspapers, visitors’ meals and refreshments, and for telephone installations. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the last inspection visit to The Peele in August 2007. A visit took place on 13 and 14 August 2008 over a period of a total of 16 hours and the home was not told about the visit beforehand. During this visit we looked around the home and looked at paperwork that must be kept by the home to show that it is being run properly. Another way that was used to find out more about the home was by talking with some of the people and staff who were in the home on the days of our visits. Some of the people were unable to express their views directly, so time was spent watching how staff talked to and supported them. The main focus of this inspection was to understand how the home was meeting the needs of the people living in the home and how well staff were themselves supported by the management of the home to make sure that they had the skills, training and support to meet the needs of those people and if the management of the home had addressed those issues identified in the last inspection report. What the service does well: Furnishings and decoration throughout the home are maintained to a good standard and provide people living in the home with comfortable surroundings. The intermediate care unit provides people with an opportunity to further build up their strength, usually after a stay in hospital, before returning to their own homes. The unit consists of 12 beds and adopts a multi-disciplinary approach to assessment, treatments and rehabilitation. Any person staying on this unit is provided with the support of other health care professionals, such as Occupational Therapists and Physiotherapists to further aid their recovery before returning home. Regular ongoing assessments are also carried out to make sure no-one leaves the unit to return home until they are well enough to do so. Comments from people using the service include “Thank you for being there for my mum – for all the weeks she spent at The Peele – you really cheered her up!” and “Thank you, to all the staff and to everyone else who contributed to my comfortable stay in Stoney Knowll (ICU)”. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 8 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 The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Prospective residents are provided with a lot of information regarding the service prior to admission and receive a full assessment of their needs. EVIDENCE: The manager confirmed that all prospective residents received a full preadmission assessment covering their needs prior to moving into The Peele. A copy of ‘Living at The Peele’ and a statement of purpose are made available to all prospective residents and information also includes the complaints procedure. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 10 We examined the files of two recently admitted residents and we saw evidence of Care Management and Nursing assessments that had been carried out by the purchasing authority before the person came to live at the home. In addition to this the manager confirmed that they or a senior member of the staff team would visit any potential new resident to find out more information and to confirm whether The Peele would be a suitable home for them. The home is also able to provide an intermediate care service to people requiring support during their transition from a stay in hospital and returning home. We visited this unit during our inspection and found the unit to be calm and relaxed with most residents watching television or spending time in their room. The unit is managed by a registered nurse who was on duty at the time of our visit as well as two other nurses and two care staff. The staff confirmed that the unit was well managed and that they felt fully supported in their roles and were confident that any concerns they may raise would be actively listened to and acted upon. Prospective residents for the Intermediate Care Unit (ICU) are referred to the Primary Care Trust (PCT) by the hospital. The PCT take the clinical lead and make sure that staff on the ICU at The Peele receive all relevant information about a potential resident prior to them being discharged from hospital. Arrangements are then made for any other healthcare professionals such as physiotherapist, occupational therapist and general practitioners to be informed of the prospective admission should they need to be involved in the rehabilitation of the resident. During our visit we saw a number of healthcare professionals visit individual residents to carry out treatments and therapies. The manager on the unit confirmed that a multidisciplinary team meeting takes place once a week. At this meeting each resident on the ICU is discussed and any action needed to enable a person to return home or stay a while longer is fully discussed and appropriate arrangements made. Information about the service is displayed on notice boards within the unit along with cards and letters from past residents of the ICU and their families. Comments included “Thank you for being there for my mum – for all the weeks she spent at The Peele – you really cheered her up!” “Thank you, to all the staff and to everyone else who contributed to my comfortable stay in Stoney Knowll (ICU)”; “On behalf of our family and of…I would like to say thank you for all your care, your patience and unfailing courtesy. You have all been wonderful in getting….fit enough to come home” and “We cannot put into words how grateful we as a family are to you all. My mum could not have been more well looked after by anyone …”. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Care plans were in place that detailed the needs of the individual resident and supporting policies and procedures were in place to ensure the safe handling and administration of medication in the home. EVIDENCE: Since our last inspection visit in August 2007 a lot of work has taken place in developing a more suitable care plan format to be used in the home that is much more person centred than the previous care plan document. At the time of our visit the manager was in the process of finalising the last stages of the changeover from the old to the new style formats. Each person living in the home has an individual care plan that had been drawn up from information contained within the pre-admission assessments and in discussion with the resident and/or their representative. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 12 We saw that the plans had been written in the first person, for example, “I need you to show me my clothes so I can choose what I would like to wear”, and “I have a zimmer frame which I use to access the toilet. I need you to escort me and assist me with my clothing. I usually go to the toilet after meals” and “I like to sit quiet in the lounge area. I like peace and quiet and don’t want to get involved in activities”. Although there was some evidence that some care plans and risk assessments had been reviewed this was not being done on a monthly basis in most cases. It is important that regular reviews are carried out to ensure up to date information about individual service users’ current needs is always available for staff to follow. Lack of regular reviews could mean that residents are not supported in the most appropriate way as their needs change. Most care plans and risk assessments had been signed by the member of staff completing them but not by the resident and/or their representative. It is important that wherever possible, residents are fully involved in any decision about how their daily life is to be supported and maintained. Day to day information about residents is recorded in ‘My Communication Notes’ and we noted that in most instances, the information being recorded was very repetitive and a number of examples were shown to the manager. On each file was a consent to share information document that some residents had signed. However, we noted that on the top of the form used to record daily communication notes was the following statement “To be completed by you and your family, friends or carers. Also the care team and health and social care staff may write here”. The consent to share information does not mention that daily recordings may be shared with family or friends or that they may record information on them. This should be reconsidered as the potential to breach someone’s privacy, dignity and human rights could happen. We saw that visits were taking place by other health care professionals such as District Nurses and General Practitioners and such visits were now being recorded in the individual daily notes for each resident. However, this information was difficult to find and it was suggested that a separate recording sheet be used on which all healthcare practitioner visits could be recorded. Since the last inspection visit in August 2007 significant improvements have taken place in the way in which medication is administered and monitored throughout the home. Managers and team leaders have responsibility for administering medication and all had received relevant training with team leaders receiving regular assessments of their competency. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 13 Each resident has a lockable metal cabinet in their room that will enable them to safely store medication should they be capable of administering their own. Discussion with the manager confirmed that risk assessments were in place for those residents who did administer their own medication but this was mainly on the intermediate care unit. We checked the medication on Brinkshaw Unit and found this to be appropriately managed and each resident requiring medication to be administered had an individual Medication Administration Record (MAR). We saw details that informed staff at what time medication was to be administered to those residents requiring it to be given “before food or after food”. A spot check of medication not contained within the monitored dosage system was undertaken and this was found to be correct. One resident was on medication to be given ‘as and when required’ and a balance check of this medication was also found to be correct. We checked the controlled drugs for Rushey Hey unit and the Intermediate Care Unit (ICU) and balances and recordings were found to be correct. We saw evidence that regular monthly audits of all medication is carried out by a member of the management team and appropriate action is taken to address any concerns that may be raised as a result of the audit. Residents spoken to told us “I get my medication when I should – they never miss” and “The doctor visits you when you need him – he leaves your prescription with the home”. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Daily routines in the home demonstrated that residents were encouraged to maintain control over their lives, were encouraged to maintain contact with the community and are provided with a wholesome and well balanced diet. EVIDENCE: Various activities are available for residents to participate in and these are advertised throughout the home. Recent activities have included a summer fair, which raised over £700:00 and barge trips to local beauty spots. There are currently two activities co-ordinators employed in the home working a total of 38 hours per week and there are plans to employ a third co-ordinator working 20 hours per week. The activities co-ordinators have been proactive in successfully obtaining a £2000:00 grant from the local government regeneration fund and will be looking at developing Information Technology (IT) for residents to use. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 15 Activities are arranged to meet the diverse needs of the residents and has included arranging things such as befrienders (Jewish) to ensure individuals’ cultural needs can be appropriately met. Maintaining contact with the community is seen as important and for one particular resident arrangements are made for their friend to visit monthly and have fish and chips together in their room. One resident told us “The Priest visits me regularly – I have communion which is important to me”. In the service user questionnaires returned to us, people living in the home told us about the activities that are available and comments included “Most activities take place in the function room” and “I take part in bingo and dancing…”. During our visit we saw lots of visitors coming to the home and the visitor’s book demonstrated that visitors frequented the home on a very regular basis. One resident told us “My son comes every week – he likes coming here – the staff are so friendly”. A notice was displayed at the reception desk informing visitors that the inspector was available should they wish to speak with him. Meal times are seen as an important part of the day and as such residents are encouraged to make choices about what foods they would like. Regular meetings between the cooks and residents take place and one resident told us “We had a meeting with the cook the other week – we told her we’ve not had ribs for a long time – they are back on the menu and we’re having them today!” The cook on duty told us that regular meetings are held to review the menus and make sure people get a good variety of seasonal foods made available to them. Discussion with the cook confirmed that soft diets are prepared where necessary and food is often prepared to meet cultural preferences for example, Jewish and Halal. Residents spoken to said “We have a good cook – made a lovely big cake for our anniversary”, “It’s cabbage and ribs today – lovely!”, “We get asked the day before what food we want – I enjoy eggs every morning” and “We could do with more gravy!”. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Policies, procedures and training measures were in place for staff to support residents to raise any issues of concern and to protect residents from neglect and abuse. EVIDENCE: The home has a detailed complaints procedure in place, which was readily available and easily accessible. Since the last inspection visit in August 2007 the home had received 24 complaints. Clear details about each complaint had been recorded on the complaints file and letters in response to each were readily available to see. All complaints had been responded to within agreed timescales and the manager told us that all had been fully concluded. The Commission for Social Care Inspection had received no complaints since our last visit to the home. Residents spoken to told us “If I had a complaint I would go to the staff”, “I would speak with the manager” and “No need to complain but if I did I would see Christine (manager)”. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 17 Discussion with the manager confirmed that three safeguarding referrals had been made under the Protection of Vulnerable Adults (POVA) procedure since our last visit to the home and all these had been thoroughly investigated with appropriate action being taken where necessary. All staff have received POVA training and the manager confirmed that all staff would be receiving refresher training in this subject. All except one member of the staff team spoken to confirmed that they had received POVA training and were very clear about the process to follow should an allegation be made. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The environment is generally clean, well maintained and comfortable for residents. EVIDENCE: All bedrooms at The Peele are en-suite and those we saw during our visit had been personalised to varying degrees and reflected the character of the person whose room it is. Most rooms we saw were clean, tidy and free from any unpleasant odours, however one room had a very strong odour of urine and the floor to the en-suite was sticky. Discussion with the manager confirmed that appropriate action would be taken to remedy this. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 19 The Peele is a large modern building that has been divided into separate units each with its own self-contained kitchen area. Although this area is not used to prepare the main meals for the day it is used to facilitate staff making fresh toast and snacks for residents and visiting relatives. Communal areas are furnished in a domestic style and are set out in such a way that residents can speak to each other rather than all face the television. In one particular lounge area we noticed that the carpet is full of old cigarette burns and looks unsightly. Although this is not posing any risk to residents it would be good if this carpet could be replaced as part of the rolling programme of redecoration and refurbishment. In the returned service user questionnaires we received back before the inspection visit took place, the majority of residents stated that the home is always fresh and clean and comments included “I do a lot myself as I am quite capable” and “There are times when carpets need more attention – stains and smells”. There is a large laundry area that is fitted with appropriate equipment and has a system in place to disinfect all laundry items in line with current infection control measures. There is also a separate lift used only for conveying soiled laundry items. The manager confirmed in the returned Annual Quality Assurance Assessment (AQAA) that staff have received training on the use of equipment and products for infection control measures. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Sufficient numbers of staff are employed in the home with staff training and development helping to ensure that staff are competent to carry out their jobs. A robust recruitment and selection process helps to protect residents from unsuitable people working in the home. EVIDENCE: Discussion with the manager confirmed that all staff, including those that have started work since the last inspection visit in August 2007 have been thoroughly vetted before they actually started working in The Peele. We looked at the personnel files of four staff, two of which started within the past six months and found all the required documentation to be in place including Criminal Record Bureau (CRB) enhanced disclosures and two written references. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 21 On the day of our visit enough staff were working in the home to meet the individual assessed needs of the residents and an examination of rotas indicated that enough staff are usually employed on a day-to-day basis. We spoke to both residents and staff about staffing levels in the home and comments included “Sometimes short staffed – they don’t have time to look for things for me when I get up”, “Wish we had more staff – especially floaters”, “..sometimes short of staff” and “Staffing levels have improved”. The manager told us that she had recently put forward a proposal to senior management to increase staffing levels in the home and this proposal had been accepted. We spoke to a number of residents about staff and they told us “Staff are ok”, “Staff are very nice” and “Staff, we would be lost without them”. We saw evidence on staff files that some training had been taking place and further training was planned. Comments from staff included, “I received relevant training within the first couple of months of starting, for example, health & safety, moving & handling and Protection of Vulnerable Adults (POVA) etc”, “We do get training, but no training happening at present”, “New starters are receiving training” and “A lot of training takes place but recently mainly for new starters, it is important they get basic training”. The manager showed us copies of training schedules that highlighted the training staff had received or were due to receive. Details within the Annual Quality Assurance Assessment (AQAA) completed and returned to us by the manager of The Peele confirmed that more than 50 of the care staff team have been trained to National Vocational Qualifications (NVQ) Level 2. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The residents living in the home benefit from having the support of a manager and management team that are able to maintain and provide a good quality service and have developed procedures to promote their interests and well being. EVIDENCE: Since the last inspection visit in August 2007 a new manager has been put in post who has many years experience of caring for older people. She has regularly updated her skills and knowledge by attending training sessions and promotes training within the rest of the management team. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 23 We spoke with both staff and residents about the management of the home and responses were very positive and comments included “We have got a nice manager – Christine, she’s a lovely lady”, “We now have more support from the manager, she is approachable and never talks down to you”, “The manager and management team are very supportive”, “Managers are very supportive and approachable” and “We now have good management – seen good improvements and we get support”. We saw evidence that regular visits are made to the home by the quality manager, business manager and the Director of Operations for the organisation. Such high level support has enabled the management team to develop clear and improved management strategies for The Peele. To promote opportunities for residents, staff and relatives to be involved in the running of the home, regular meetings take place where topical issues relating to the home are discussed and minutes of these meetings were made available during our visit. Although no quality audit of the service has taken place since our last inspection visit in August 2007 the manager told us that an audit was planned to be carried out and completed by the end of December 2008. The manager told us that she regularly carries out spot checks during the night to ensure that residents are comfortable and that staff are maintaining an appropriate level of care. Those night staff we spoke to on the second day of our visit confirmed this and also told us that they valued the opportunity to meet with the manager when she does carry out such unannounced visits. Where management dealt with the personal allowances for individual residents a record of balances was kept with receipts obtained. Two staff witness and sign all transactions carried out on behalf of individual residents. It was confirmed within the written information provided by the manager prior to this visit taking place that all routine maintenance and servicing of equipment used in the home has been carried out and a random selection taken from these service records during our visit confirmed this. The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations a) Care plans and risk assessments should be reviewed on a monthly basis or sooner if necessary. b) Where possible, residents and/or their representatives should sign care plans and related documentation. c) Consideration should be given as to who can have access to and record in individuals’ daily notes. d) Consideration should be given to recording healthcare professionals visits on separate documentation to the daily notes for individual residents. Consideration should be given to replacing the cigarette burned carpet in the lounge identified to the manager. 2 OP19 The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 The Peele DS0000066003.V364667.R02.S.doc Version 5.2 Page 28 - 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!