Care Home: Peacock Hay

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What the care home does well The service has information about its aims and type of home it is, for prospective users of the service so they can and their supporters can make a decision about if it is suitable for them and can meet their needs. A guide has been produced in simple language and pictures so that it can be more easily understood. Prospective users of the service are assessed prior to moving into the home. The service uses a person centred approach to care planning; this means that every effort is made to ensure that the individual is supported to make decisions about their goals, needs and aspirations. Plans are then put in place to support them to achieve what they want to. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Records show that people’s health needs are being monitored and met, and medication management appears to be satisfactory. The environment is of a good standard and is well maintained and decorated. People using the service told us, ‘They feed us and take us on activities.’ ‘Meets my needs everyday, takes care of me and provides a nice warm clean home.’ ‘The home cares for all my needs and looks after my interests to the best of their ability.’ ‘I have no issues with staff or living here it looks after my needs well.’ What has improved since the last inspection? A new manager has been recruited and staffing numbers have improved. People using the service are going out of the home more frequently. Risk assessments are in place for each individual. The service is making efforts to involve relatives in decisions about how the service intends to develop. What the care home could do better: We discussed the need for the service to ensure that the arrangements for the management and administration of medication are improved. People using the service told us, ‘The home could do better with more transport.’ ‘Sometimes we need more staff for activities.’ The service should ensure that staffing numbers are sufficient to meet the needs of people using the service and that staff received regular one to one supervision sessions and staff meetings. A review of how some training is provided should be considered so that there is confidence that staff have received practical sessions where appropriate and been assessed as competent. The service must ensure that events that adversely affect people using the service are reported to us and the relevant agency. The manager needs to apply to be registered and approved by us.Peacock HayDS0000068617.V377738.R01.S.docVersion 5.3 Key inspection report CARE HOME ADULTS 18-65 Peacock Hay Peacock Hay Road Talke Stoke on Trent Staffordshire ST7 1UN Lead Inspector Wendy Jones Key Unannounced Inspection 17-24 September 2009 12:35 Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Peacock Hay Address Peacock Hay Road Talke Stoke on Trent Staffordshire ST7 1UN 01782 786918 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) peacockhay1@tiscali.co.uk londonroad@tiscali.co.uk Milbury Care Services Ltd Post Vacant Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD) 7 The maximum number of service users who can be accommodated is: 7 20th October 2008 Date of last inspection Brief Description of the Service: Peacock Hay is privately owned by Milbury Care Services and is registered to accommodate 7 adults with learning disabilities. People who use the service have varied abilities and may have communication difficulties, have autism and present with challenging behaviours. The home is situated on Peacock Hay road, off the main A500 at Talke, Staffordshire. The premises was formerly a guesthouse has extensive grounds, adequate parking and has been converted into a spacious care home. The property sits in an estimated ¾ acre of land. The immediate area around the home has been developed to provide suitable gardens and patio areas for the people living there. The main driveway is up a steep incline that leads to the large car park to the right of the home. Access to the front entrance is via a ramped pathway, which has handrails positioned on each side. People who may use the service and their supporters should approach the provider for the fee range and costs of the service. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection visit undertaken by two regulation inspector on 17 September 2009. Formal feedback was given to the manager on 24 September 2009. In total the visit took approximately 12:00 hours. The purpose of this visit was to assess the services performance against the National Minimum Standards and to establish if it provides positive outcomes for the people who live there. The visit included checking that any requirements and recommendations of the previous inspection visit of 29 October 2008 have been acted upon. And standards have been maintained since the random inspection visit of 30 April 2009. We have been provided with an Annual Quality Assurance Assessment (AQAA), which is the service’s own assessment of its performance, and have used exerts from it. We received completed surveys from relatives, staff, people who use the service and health professionals. Comments are included in the main body of this report. We looked at care and health records, personnel files; staff rota’s and staff training information. We spoke to staff, people using the service, relatives and management. We observed interactions and checked other relevant information and undertook a brief tour of the building. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We have made 2 requirements and 9 recommendations as a result of this visit. What the service does well: The service has information about its aims and type of home it is, for prospective users of the service so they can and their supporters can make a decision about if it is suitable for them and can meet their needs. A guide has been produced in simple language and pictures so that it can be more easily understood. Prospective users of the service are assessed prior to moving into the home. The service uses a person centred approach to care planning; this means that every effort is made to ensure that the individual is supported to make decisions about their goals, needs and aspirations. Plans are then put in place to support them to achieve what they want to. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 6 Records show that people’s health needs are being monitored and met, and medication management appears to be satisfactory. The environment is of a good standard and is well maintained and decorated. People using the service told us, ‘They feed us and take us on activities.’ ‘Meets my needs everyday, takes care of me and provides a nice warm clean home.’ ‘The home cares for all my needs and looks after my interests to the best of their ability.’ ‘I have no issues with staff or living here it looks after my needs well.’ What has improved since the last inspection? What they could do better: We discussed the need for the service to ensure that the arrangements for the management and administration of medication are improved. People using the service told us, ‘The home could do better with more transport.’ ‘Sometimes we need more staff for activities.’ The service should ensure that staffing numbers are sufficient to meet the needs of people using the service and that staff received regular one to one supervision sessions and staff meetings. A review of how some training is provided should be considered so that there is confidence that staff have received practical sessions where appropriate and been assessed as competent. The service must ensure that events that adversely affect people using the service are reported to us and the relevant agency. The manager needs to apply to be registered and approved by us. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 8 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 Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be confident that they will have information provided which enables them to make a decision about the service and if it can meet their needs. EVIDENCE: The service told us in the AQAA that, “We have used a consistent and thorough assessment approach that ensures potential service users have as much information as they can about the service we offer. We also ensure we gain all relevant information necessary to provide a diverse, person focussed and appropriate service that can meet each individual’s needs.” We saw that the service provides a Statement of Purpose with information about the type of service it is, and its aims and objectives. Each person using the service has a copy of the service user guide in their records, this outlines the terms and conditions of the service. The manager told us that both documents are being updated. We looked at the records of one person who has been admitted to the service since the last key inspection. We saw that assessments have been completed Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 10 prior to admission; there is some evidence to show that the individual has been involved in the decision to move into the home. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have support plans that address their assessed needs. EVIDENCE: The service told us in the AQAA that, “Each service user has an individual care package. The package covers all aspects of the individual’s needs including health, social, communication and personal needs. These are discussed with service users to the best of there ability to understand and where choice is restricted due to planned intervention; the reasons are explained to them. Regular reviews of care packages take place and any changes are discussed in full then monitored to ensure suitability. Full reviews also take place where family and professional’s re- assess the needs with the service user to ensure quality of care is maintained.” We have been told that a review of the person centred and support plans are Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 12 being undertaken to ensure that they are more user friendly. The current records are cumbersome, not always easy to follow and in some instances can be repetitive. We looked at three peoples support plans, we found that people’s needs are well documented; we saw that efforts have been made to include people in the care plan and decision making. But this can be improved. We saw in one persons records that staff have signed to say that they have read Support Plans. But the person’s relevant Key staff have only signed the first few and have not signed to ay they have read others including the Medication Support Plan. It is recommended that these Key staff members sign that they have read these in order to ensure that staff who are directly delivering care understand and are able to meet people’s care needs. We saw in one example where a person can present with challenging behaviour. Staff have completed risk assessments and management strategies, we observed these strategies in practise during our visit. Staff told us in surveys that the service caters for people’s needs and provides good support. ‘The service provides good quality care.’ ‘We would benefit from more experienced staff.’ ‘Some staff continue to make decisions that are not always in the best interests of service users, but suit themselves.’ Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 13 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): This is what people staying in this care home experience: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service opportunities to be engaged in a varied range of activities is improving. EVIDENCE: The service told us in the AQAA that, ‘We ensure that all service users have regular access to local community facilities. We promote a positive image and support service users to visit many local community resources, such as colleges, gymnasiums, local pubs / cafes / restaurants, shops, swimming baths and places of interest, amongst others. In doing this we hope to promote real and valid friendship between service users and people in their local community.’ Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 14 We saw that there have been some improvements in the opportunities people have to be engaged in activities in and out of the home. And a relative told us, “They take our relative swimming several times each week” We saw that people have been enrolled on college courses where possible, although the acting manager stated that this is becoming more difficult due to the limited availability of courses locally. During our visit one person was out with his key worker, another at college, two people went out for lunch, another went out to the theatre and another person went out shopping. In one persons support plan, we saw that her goal was to attend college but this has yet to be achieved, her key worker stated that they were looking for a suitable course for her. We also a Cultural and Spiritual Expression Risk assessment for each person, which identifies their spiritual and cultural needs. People told us in the surveys that, ‘We need more to do and more staff to take us out.’ Staff said, ‘we could possibly do with another vehicle and personal telephones in case of emergencies when out.’ ‘We meet the individual needs of service users and offer a varied choice of activities.’ ‘We could get the service users out more, and have more staff so that we can have more one to one time.’ We spoke to two people about what they liked to do, one person said she liked swimming and shopping, another said she liked to go to a disco. We saw an activity timetable for one person that was displayed in the individuals’ bedroom. Activities included, swimming, food shop at Asda, sensory session, pub trips, make-up and disco session, laundry, personal shopping, visit to library, crafts/activities, visits to Pets At Home. DVDs, visits to Westport Lake. We looked at the food people are being provided. We saw that individual records show individuals’ likes and dislikes. Each person has a personal menu planner in addition to a record of the food actually chosen. Where communication is difficult the service has photographs of food items and meals for individuals to choose from. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be confident that their health needs are assessed and known, but need to be sure that the service provides the support required to meet them. EVIDENCE: The service told us in the AQAA that, ‘Service users at Peacock Hay are supported on a 1:1 basis in most instances – this is based on their assessed and perceived needs to ensure their well being. Personal support is provided in the individual’s preferred way as defined in their plan of support. We ensure that service users’ individual capabilities are assessed and reviewed regularly and that they are given the opportunity to administer and control their own medication in conjunction with their medical professional’s guidance.’ We looked at records of three people using the service, we saw that each person has a health action plan; this information describes the health needs of the person and what the staff must do to ensure that the needs are met. This Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 16 can include making sure that people have regular health checks i.e. dentist, GP or chiropody or attend specialist health clinics. It also may include day to day monitoring of a persons well being. We saw one plan which stated that a persons’ diet and weight needs to be monitored we looked at the records for this. We saw that this persons’ weight was not being monitored as regularly as the plan said it should, and found that the records of fluid and dietary intake have not always been accurately maintained, or are not in enough detail to determine if the person’s intake is sufficient. We spoke to the manager about this. We looked at another person health records, we saw that the plan stated that there should be regular blood tests, but we couldn’t see from the records that these had been completed. We looked at medication management, storage and administration. We saw that the records have been properly maintained generally, although staff signatures were missing on one Medication Administration Record (MAR) for the 5 and 6 September 2009. We talked to the acting manager about the services’ policy for this. We saw that protocols for as required medication have been written for the majority of medications prescribed, so that staff know when they should be given. We found one example when this hadn’t happened and recommend that the service ensure that a protocol has been completed. We tried to complete an audit of medication but couldn’t because there was insufficient information available. We have recommended that the service maintains accurate records of all medication received in the home, and maintains an on going record of the stock of medication in the home including the quantity of medication carried forward. We saw that the storage facility for medication is satisfactory. We spoke to staff about medication training and have been told that all those responsible for the administration of medication have been trained to do so. We also saw a record indicating that staff have been assessed as competent to administer medication. We talked to staff about health training we have been told that staff have received first aid training via a computer training resource, the EL box. We recommend that First Aid be taught in a practical way so that people can be assessed as competent. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service need to be sure that they know how to make a complaint or who to go to if they are not happy. And that the service will report any suspected abuse. EVIDENCE: The service has told us in the AQAA that, ‘we have a robust polices and procedure to deal with concerns, complaints and any protection issues. All staff, prior to employment, undergo necessary POVA, Enhanced CRB and reference checks.’ We looked at the records of the complaints we ask services to keep, we saw that they have responded to the complaints they have received. They told us in the AQAA that the service has received 6 complaints and have been involved in 2 safeguarding investigations since the last inspection. The service has recognised that it has needed to make improvements in this area and has introduced relatives meetings on a regular basis and hopes to improve communication with them and other stakeholders. The frequency and content of house meetings for staff and people using the service will also be reviewed. The acting manager stated that she wants to look at how the service can involves people using the service more in the day to day decision making in the home. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 18 We noted in the records of a staff meeting that a theft had occurred earlier in the year, according to our records we have not been made aware of this. Three people using the service told us in the surveys that they know how to make a complaint and who to go to if they have any concerns, but three people said that they didn’t. We saw that the service has a complaints procedure that has been revised and produced in a more user friendly format. But recommend further work is undertaken to ensure that all of the people using the service know what they should do if they have any concerns. We spoke to people using the service and a relative during our visit, they said, ‘I like living here, but sometimes it gets noisy and I don’t like that.’ ‘I’m okay.’ The relative confirmed that, ‘They keep us informed if there has been a problem and if we have any concerns we have been able to sort them out satisfactorily.’ We spoke to a member of staff about training and have been told that staff have received safeguarding training, but the member of staff wasn’t sure about the Mental Capacity Act or Deprivation of liberty. We saw that staff has signed to state that they have read information on Safeguarding and protection of vulnerable people, Mental Capacity Act and Deprivation of Liberties. We recommend that staff receive this training and that service reviews support records and individuals to ensure that people’s freedom/liberties are not restricted. We looked at a sample of three staff recruitment records. The service uses a checklist to ensure that all the relevant records and checks have been carried out. We found these were generally satisfactory. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be sure that the home in which they life is well maintained comfortable and safe. EVIDENCE: The service told us in the AQAA that, ‘The home is set out to provide care of seven people, each with their own ensuite room with either a bath or shower. The home is bright, cheerful, airy, clean and free from offensive odours and provides sufficient light, heat and ventilation. The home offers access to local amenities, local transport and relevent support services to suit the personal and lifestyle needs of service users and the purpose of the home. The home style fits in the ambience, type of home within the community and reflects the homes purpose.’ We found that the home is well maintained and provides a good standard of Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 20 environment for the people who live there. There is a spacious main lounge and a second room that combines an activity are, comfortable seating and dining space. There is a separate dining area. The kitchen is accessible and of domestic style and design. We saw one person’s bedroom, it is much personalised, with evidence that the individual has been supported to make her room as comfortable as possible. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service must be confident that staff are being properly supervised and are provided in sufficient numbers to meet their needs. EVIDENCE: The service told us in the AQAA that, ‘The staff team work to policies and procedures, legislative guidance and current initiatives and standards. Through effective management, we are able to determine staff understanding and address any development needs via a two way and respectful process, ensuring that all staff feel confident to approach others for support. All staff are supervised, monitored and appraised by the management team and throughout their induction and probationary period are set clear and reasonable objectives. Each staff member has an appropriate development plan formed during their annual appraisal and this sets further objectives for the coming year.’ Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 22 We saw from the staff record and other information made available to us that staff have not received a 121 supervision session as frequently as we have recommended. The manager confirmed this to be the case, but also stated that the organisation have asked her to ensure that all staff have a supervision session by the end of September. We spoke to one member of staff who confirmed that supervision has been planned. We looked at staff meeting records after we were told that they are held every month approximately. The last record of a meeting we saw is dated 09/04/09. We asked staff if they could find the records of other meetings but they couldn’t. The last recorded managers meeting is 15/04/09, We asked the acting manager to provide us with an up to date list of training that has taken place. We spoke to a member of staff, who has recently started and is in the process of completing induction training, they said, “I have nearly finished all the subjects on the EL Box (computer). I have an induction book which is signed off by a senior mentor when completed. He confirmed that he “shadowed” a member of staff for 2 weeks when he first started. The records of staff roster’s show that the week of the visit, the staffing levels are 6/6 with additional management hours, but the previous week were 5/4 this is less than the minimum staffing levels agreed to provide people with the one to one care they are assessed as needing. We saw that the agreed weekly hours equate to 825, but the service is currently operating on 649. The acting manager stated that recent recruitment drive has meant that more staff have been employed and once pre employment checks have been carried out most vacancies will have been filled. In total the service is waiting for 5 new starters and another person who will be transferring form another of the organisations services homes. We noted in the AQAA that 12 staff have left since the last key inspection visit, this appears to be a high turnover of staff, but the operational manager said that all have left for genuine reasons We looked the recruitment records of 3 staff all were satisfactory except one that did not have a CRB. The ops manager contacted the Human Resources officer, and confirmed that CRB has not been returned. This person has been employed since May 2009, a POVA has been carried out and there are 2 written references on file. We has mixed comments in staff surveys, the service needs to act to address the matters raised. Staff have said in the surveys that, ‘Generally the home does most things well, has been more organised since new manager has started.’ ‘We need more staff and ensure that new staff are given the training they need straightaway and not weeks and weeks after starting.’ ‘Practical first aid is needed not just EL box training.’ ‘I have only been here a short time and have been welcomed into the service by all management and staff really well.’ ‘We could do better by building a Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 23 consistent staff team who are well trained and have the knowledge to offer the service expected by management, purchasers, families and service users.’ ‘My experience at Peacock Hay so far has been very positive. The staff team are striving to improve daily as their knowledge’s and experience grows and so does the relationships between carers, families and service users. I feel that Peacock Hay has turned a corner and is now on track to fulfil its potential.’ ‘They could have a better standard of support with better staffing it is not running to its best capability. If there was an emergency staff would struggle through no fault of their own.’ ‘Staff are not gelling together and training could be better, it has left staff with poor confidence and faith in the service.’ ‘We need more experienced staff and staffing levels.’ ‘Agency staff do not know the home well enough to offer support. I have worked night with agency staff and have not felt comfortable. Staff training has been done on the EL box a feel this is not a good way of showing first aid and food hygiene skills.’ ‘The service would benefit from a more settled staff team.’ ‘Some staff continue to make decisions that are not always in the best interests of service users, but suit themselves.’ Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service must be sure that the service is properly managed. EVIDENCE: Information in the AQAA tells us that the service has recruited a new manager since the last key visit. She was present throughout this key visit, has experience of managing care settings and understands that she needs to apply to register with us. Staff told us in surveys that, ‘It’s better here now a new manager has been appointed.’ Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 25 We received the AQAA when we asked for it to be returned. It contains detailed information about the service and how it meets the standards expected. But we have found that we could not evidence some of the things we have been told in it. This means, we cannot always be confident that the service is doing it what it says it is. The service has kept us informed of events in the home, we have been notified of two incidents/accidents since the last inspection visit. And have received two notifications of safeguarding referrals. But we noted in staff meeting records that a theft had occurred in April, we have not received a notification about this as we would expect to. We spoke to the acting manager about this. The provider ensures that the service is monitored regularly by undertaking monthly visits to the home and reporting on the findings. These reports are available in the home. We have been told in the AQAA that servicing and maintenance of equipment is up to date. We checked that the service is meeting it’s obligations with fire safety and that staff have attended fire training and drills. We saw evidence of this, The acting manager told us she has been asked to identify how the service can improve, and she will be producing a development plan with the operation manager to evidence the improvement she wants to make. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 26 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 3 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 2 23 2 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 3 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 x 2 x 2 x 3 Version 5.3 Page 27 Peacock Hay DS0000068617.V377738.R01.S.doc 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. 1. Standard YA20 Regulation 13(2) Requirement The service must ensure that accurate records of medication stored in the home are maintained, to enable an audit of medication to be completed. The service must ensure that medication administration records are completed at the time medication is administered. Timescale for action 30/12/09 2. YA20 13(2) 30/12/09 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. 2. 3. 4. Refer to Standard YA6 YA12 YA19 YA19 Good Practice Recommendations The service should make further efforts to include people using the service in decision making, through person centred planning. The service should continue to pursue meaningful activity both in and out of the home for people using the service. The service should ensure that people using the service have their health needs monitored at the frequency the plans say they should. The service should ensure that where health needs have DS0000068617.V377738.R01.S.doc Version 5.3 Page 28 Peacock Hay 5. 6. 7. 8. 9. YA22 YA23 YA37 YA23 YA39 been identified the records show how these have been met. The service should ensure that people using the service know how to make a complaint and who to go to if they are unhappy. The service should ensure that thefts in the home are reported to us and the relevant agency. The acting manager should apply to register with us to be approved as a fit person to manager the service. The service should ensure that staff have received guidance and training re Mental Capacity Act and Deprivation of Liberty The service should provide us with an annual development plan. Peacock Hay DS0000068617.V377738.R01.S.doc Version 5.3 Page 29 Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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