Care Home: Peregrine House

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What the care home does well The home has a relaxed and friendly atmosphere. There is sound support provided for the people living there, with choice, individuality and independence demonstrably valued. People living in the home said that they felt respected and well cared for. Relatives gave similar feedback. Peregrine House is committed to build its capacity to better meet the needs of people with mental health needs. It is a developing a plan of action for this work. The service has a proactive and forward thinking approach to the changing needs of its residents and prospective residents. The Registered Manager continues to be supportive, effective and proactive. She has excellent support from Servite Houses management and the organisation`s resourcing. This is a real strength, which nurtures the culture of the home and makes it a good place to live. What has improved since the last inspection? Risk assessments are now in place for all people living in the home. Information about whom to contact when there is a concern about safeguarding the welfare of the residents has been updated. Staff have been trained in safeguarding adults. CARE HOMES FOR OLDER PEOPLE Peregrine House 350 Hermitage Road South Tottenham London N15 5RE Lead Inspector Margaret Flaws Unannounced Inspection 17 July 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Peregrine House Address 350 Hermitage Road South Tottenham London N15 5RE 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) 020 8809 5484 020 8802 1471 Servite Houses Ms Yvonne Evadney Smythe Care Home 35 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (35), Old age, of places not falling within any other category (35), Physical disability (16), Physical disability over 65 years of age (35) Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 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: Old age, not falling within any other category - Code OP Mental disorder, excluding learning disability or dementia, over 65 years of age - Code MD(E) Physical disability - Code PD (maximum number of places: 16) 2. Physical disability, over 65 years of age - Code PD(E) The maximum number of service users who can be accommodated is: 35 29th August 2007 Date of last inspection Brief Description of the Service: Peregrine House is a large care home for up to thirty-five service users, the majority of whom are older people but there is a significant group of younger service users with physical disabilities. The home is run by Servite Homes. The home is located in a residential road in South Tottenham. It is sited close to local shops, public transport and local amenities. The home is organised over two floors, with the ground floor functioning as a specialist unit for up to sixteen younger people with physical disabilities. All bedrooms are for single occupancy and have en-suite facilities. There is a lift and a number of assisted bathrooms. There are patio areas with raised tubs which are accessible to service users. The stated aims of the home are: ‘Peregrine House offers care and support to enable residents to remain as independent and active as possible. Each person Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 5 is treated as an individual with his or her own likes and dislikes.’ The home provides twenty-four hour care and support and access to a range of residential specialist services geared towards meeting individual service users needs. Fees charged at the home range between £452 and £750 per week. A copy of this Inspection report can be requested directly from the home or via the CSCI website (web address can be found on page 2 of this report.) Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day. The Registered Manager was available throughout the inspection. We spoke to most people living in the home, two relatives, seven staff and three visiting social and health care professionals. We toured the premises throughout the day and examined the home’s records and policies as part of the inspection. These records included care and staff records, health and safety and general home records. The Registered Manager assisted throughout the inspection. The home provided CSCI with an Annual Quality Assurance Assessment (AQAA), which also informed this inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. What the service does well: What has improved since the last inspection? What they could do better: Procedures for working with people who have an infectious conditions, like MRSA, should always be clearly documented in each person’s care plan. Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 7 The home must improve temperature regulation in the building, which can become too hot. A problem with the hot water mixer must be resolved to ensure that all residents have access to hot water, including hot water in their rooms. All staff should participate in a mental health training programme to better meet the needs of residents with mental health issues. This should include ongoing training in working with challenging behaviour. It is recommended that the service strengthen its mental health plan and provide a copy to the Commission for Social Care Inspection. Training for staff infectious diseases would be improved if it were broadened in its scope. 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. Peregrine House DS0000010734.V364734.R01.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 Peregrine House DS0000010734.V364734.R01.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, 4 People who use this service experience good quality outcomes. This judgement has been made using available evidence including a visit to this service. Prospective residents have their needs comprehensively assessed prior to moving into the home. EVIDENCE: Comprehensive assessments are completed for all prospective residents prior to admission. We examined four care files for new residents. These contained full assessments of need, which formed the basis of clear care plans. These assessments help staff at the home to understand each new resident and plan to meet their needs. The assessment procedure is clear. The Registered Manager visits the prospective residents in their homes or in hospital to make a new assessment. Placing authorities provide statutory assessment information and this is kept on each file. Pre-admission visits for prospective residents are actively encouraged, with trial stays of up to six weeks possible. Visiting social workers we spoke to were positive about the thoroughness of the assessment procedure. Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 10 On the day of the inspection, there were thirty people living in the home, three vacancies and two people in hospital. Several London local authorities place people in the home. With the Registered Manager, we discussed the changing demographic profile of people being referred to the home. There are an increasing number of mental health referrals. The home has good relationship with a mental health acute hospital and community mental health services in the area, which are the main referrers. At present, there are ten people living at Peregrine House with mental health needs, double the number from the last inspection a year ago. We discussed the capacity of the home to meet peoples’ mental health needs. The Registered Manager said that the home is in ongoing discussions with local authority commissioners on how it intends to improve services for this group. She also said that Peregrine House is working on a mental health support and service development plan and will continue to improve resourcing in this area. It is recommended that the service strengthen this plan to ensure that it covers all areas of the service as a matter of good practice. A copy should be sent to the Commission for Social Care Inspection. One consequence of the change is that mental health referrals have a longer assessment process and lead time, because of the need to go through local mental health panels for each placement. This means that trial stays by prospective residents are staggered over several visits of increasing length to help people decide whether or not the home is suitable for them. People I spoke to said that they had had a good opportunity to see whether the home could meet their needs. Other specific steps being taken to improve mental health outcomes for residents are discussed in other sections of this report. Peregrine House DS0000010734.V364734.R01.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 People who use this service experience good quality outcomes. This judgement has been made using available evidence including a visit to this service. Everyone living the home has a generally good quality care plan and his or her healthcare needs are assessed and met. Risks are appropriately assessed, to help people develop and to protect them from harm. Residents are protected by the home’s policies and procedures for medicines and they are treated with respect, with their privacy valued. EVIDENCE: Four files of people living in the home were examined. All had good quality care plans, which have progressively improved in consistency and quality. Objectives had been discussed with the people living in the home, documented and agreed to. These plans are systematically reviewed along with the residents. Peoples’ healthcare needs are reviewed and addressed. Appointments with healthcare professionals and others (such as opticians and dentists) were Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 12 clearly planned for and outcomes documented on the residents’ files. District nurses visit the home daily to give insulin injections, change dressings etc. Mental health professionals provide specialist support for those residents with mental health issues. Risk assessment and risk reduction plans have improved. In the care plans we sampled, risk assessments were clear, with risks outlined and actions to take in relation to each risk detailed. Senior staff have been trained in care planning and risk assessment since the last inspection and a better systems for monitoring care plan and risk assessment reviews actioned. There have been incidents recently where the behaviour of some residents challenged staff and other residents. Generally, these have been well managed and communication between staff, residents and other services has been good. However, as part of the plan for meeting the needs of people with mental health issues (discussed in the Choice of Home section of this report), incident management and approaches for dealing with challenging behaviour should be considered. A day on managing the risk of falls was held recently and handrails have been fitted in the corridors to improve safety. We discussed how infection control is managed in the home with staff and the Registered Manager. Where a resident has MRSA, there is a clear procedure in place and staff were observed to be following this procedure. However, this was not clearly documented in one person’s care plan and a requirement is given. There had also been debate amongst the staff team about the management and risks of tuberculosis. A recommendation is given in the Staffing section of this report to address this as a training issue. Two visiting health and social care professionals we spoke to were pleased with the home and said that the needs of the people they worked with were very well met there. The medication policy and procedures were inspected. The home operates a monitored dosage system of medication administration. No issues were identified on this inspection. There were no gaps or discrepancies in the Medication Administration Records (MAR) sheets; there were clear records of medications received into the home and disposed of; staff we spoke to had been trained to handle medication safely and the medication systems in place were good. The home has a good policy and procedure on Same and Cross Gender Personal Care. Peoples’ preferences are documented in their care plans. We spoke to several people living in the home and two relatives during the inspection. They all said that they were treated respectfully. One said that they felt good about living there because the staff and the manager were thoughtful. Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 13 We saw the organisation’s Equality and Diversity Policy. This gives the home a sound base to work from to support for peoples’ individual needs. The home holds an International Day celebration each year to recognise the breadth of the communities represented at Peregrine House, in addition to other festival days. Over one third of the residents are Afro Caribbean and African and some are residents are Jewish or Muslim. People we spoke said that they felt their cultural beliefs were respected and honoured. From observation, the staff clearly knew the residents well and key workers were able to describe the needs of the residents they supported. There are private areas in the home for people to meet and socialise as they wish and people do move around freely between the units. Peregrine House DS0000010734.V364734.R01.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 People who use this service experience good quality outcomes. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from a range of social and community activities, to help meet their social needs and expectations. Family involvement is supported and people are supported to keep control over and choice in their lives. The food on offer at the home is healthy, nutritious and culturally varied. EVIDENCE: Most people living in the home live active lives. The home offers reasonable lifestyle options for them to choose from. There is a weekly programme of activities including outings, visits to the cinema and art galleries, games, mobile library visits and other events. Some residents also help in the day to day running of the home. As a result of feedback from the last annual survey, an annual activities programme has been developed and the home is seeking to recruit an activities coordinator. On the day of inspection, people participated in a social morning where residents from the four units got together in the downstairs lounge and shared morning tea and entertainment. Entertainers and musicians come to the home regularly and people go out into the local community. Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 15 People living in the home are supported to maintain contact with their families and friends as they wish. Faith needs are supported with opportunities for attendance at religious services in the community and regular spiritual visitors to meet peoples’ needs. The home has Muslim, Jewish, Christian and Hindu residents. Celebrations and meeting specific cultural needs are part of the life of the home. There are regular residents’ meetings for people to give their views and determine for themselves what happens in the home. Meeting minutes showed that vigorous discussions took place in these meetings. People we spoke to were happy with living in the home. Typical comments were: “I like it here – I tell them everything I want or would like and they help me”. “They’re a good support – I trust them”. Relatives were also positive: “mum is very happy here, staff have an excellent relationship with her. They are respectful of her cultural needs too. I just come anytime I want and take her out.” Another relative who visits weekly said that her mother was very well cared for and that this was a “good place” for her. A contracted catering company provides the main meals served in the home. The main kitchen inspected was clean, tidy and functional. Fridge and freezer temperatures were recorded daily. There is a new dishwasher installed. Menus offered good choices. In each lounge, there is a pictorial meal chart for each day so that residents can see and then choose what they would like to eat. Good vegetarian options are available. Meals and preferences are discussed at resident’s meetings. The home has a culturally diverse group of people living there and their dietary needs are addressed in the menus. For example, a full Caribbean meal is provided weekly. One relative said that the quality of this food was excellent and that her mother enjoyed it. Other people we spoke to were generally positive about the quality and quantity of food on offer. There were good stocks of food in kitchen and the lunch was healthy, nutritious and appetising. Peregrine House DS0000010734.V364734.R01.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 People who use this service experience good quality outcomes. This judgement has been made using available evidence including a visit to this service. People living in the home can be confident that their complaints would be dealt with appropriately. The home has sound adult protection policies and procedures in place to protect the residents. EVIDENCE: The home has an appropriate complaints policy and procedure, which is clearly displayed for residents, their families and friends to see. Detailed complaints records show that complaints are investigated and addressed appropriately. Complaints now go into Servite Homes online complaints systems for monitoring and follow up. Two people we spoke to said they had no concerns about making a complaint and that they would go straight to the manager if they were unhappy. The Registered Manager and staff said that residents’ confidence had grown since they saw how the home managed a specific safeguarding issue. Peregrine House follows a sound safeguarding policy and procedure and is good at keeping CCSI informed of matters of concern for the residents. Good, detailed reports are produced. The publicly displayed contact details for CSCI and the local authority have been updated, along with the adult protection procedure. A requirement from the last inspection is met. Since the last inspection, there have been four safeguarding referrals to the local authority. Two of these referrals involved detailed investigations. One is Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 17 now resolved (the outcome was that the allegation was unsubstantiated) and the other is still in process. The Registered Manager said that one of the safeguarding issues was difficult for everyone involved but had also been an important opportunity for learning. The Registered Manager continues to sit as an advocate on the local safeguarding adults champions’ committee. She showed us a new book on safeguarding produced by one of the trainers that the home uses. The book had detailed examples and scenarios on potential safeguarding concerns. The Registered Manager said that she regularly uses these scenarios in one to one supervisions and team meetings with staff to check their understanding of the issue. Formal staff training in safeguarding adults has been updated, meeting a requirement from the last inspection. The training programme has focussed on safeguarding in the past year, with all staff completing one full day’s training and senior staff moving on to advanced safeguarding training. Staff gave sound responses, including examples, about how they would recognise and address potential abuse. Peregrine House DS0000010734.V364734.R01.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 People who use this service experience good quality outcomes. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and well-maintained environment. The home was clean, pleasant and hygienic. EVIDENCE: The home is purpose built and people live in four semi self-contained units, which have their own kitchen and dining areas. People move freely between the units and are able to spend time where they prefer. Those we observed doing this appeared to enjoy having social networks around the building. The home is comfortable and well maintained. We spoke to the handyman. He said that three bedrooms had been re-carpeted and redecorated. These rooms were pleasant, light and nicely fitted out. However, when we tested the hot water in one room (presently unoccupied), it took a very long time to come through and was cool. We discussed this with the Registered Manager, who said that she is aware that there is a problem with the hot water mixer. A Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 19 requirement is given that the home ensures that hot water is always available to residents, including hot water in their bedrooms. The temperature in parts of the home seemed quite hot for the relatively warm inspection day. Some residents and staff confirmed that the home felt too hot inside. Another requirement is given - that the home improve temperature regulation in the building. A new maintenance tracking system has been initiated across Servite Homes. The Registered Manager said that this makes it easier to keep tabs on the progress of a major maintenance request and follow up any delays in a job being done. We visited several peoples’ bedrooms. These were personalised with pictures, photographs and ornaments. People we spoke to said that they liked their rooms and found them comfortable. The home was clean, tidy and odour free during the inspection. Domestic staff have been trained in handling dangerous chemicals, infection control, health and safety, dementia and appropriate language to use in the home. . Peregrine House DS0000010734.V364734.R01.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 People who use this service experience good quality outcomes. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by appropriate numbers of appropriately recruited and trained staff. EVIDENCE: The home has a relatively low staff turnover and many staff have worked in the home for a long time. In the six files we sampled, staff had been recruited in an appropriate manner. Application forms were completed, in-depth interviews held, written references taken up, Criminal Records Bureau checks undertaken and photo identity obtained. The home incorporates equal opportunities into its recruitment process. Staff follow the National Skills for Care formal induction programme. One new staff member described a thorough induction she was completing. Rotas accurately reflected the staffing in the home on the day of the inspection. Residents said that there were enough staff on duty to help them and that they didn’t usually have to wait for a staff member to respond to their needs. Six carers work on each shift, with one staff member allocated for each unit and two “floating” staff between units. There is a separate domestic staff team. The manager or a duty officer is always on duty to manage the home. Three carers cover the home overnight. Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 21 The home continues to make good progress supporting staff to achieve National Vocational Qualifications (NVQ). Over 50 of staff have either NVQ2 or NVQ3. Training records demonstrated that a wide range of training has taken place. Staff spoken with confirmed that training opportunities were always available and that there has been a boost to training opportunities in the past year. Safeguarding, advanced infection control, updates for manual handling, first aid and food hygiene were prioritised. The home has just had a manual handling audit and is waiting for the results before putting further training in place. While it was clear in the evidence we examined that many staff had had good training in infection control, it would be useful for the home to ensure that any future training included opportunities for staff to address any fears they might have and learn how the actual risks of particular infectious diseases. A recommendation is given. The Registered Manager now has a large wall chart in her office and another in the staff room showing training completed by each person, making it very easy to see what training has been completed and what is needed. The Registered Manager said that mental health training will be extended and more mental health professionals become involved in delivering training. Peregrine House staff will also shadow mental health professionals in the community as part of their learning. A requirement is given that all staff participate in an ongoing training programme to better meet the needs of residents with mental health issues. This should include training in challenging behaviour. All staff have had one day’s equality and diversity training, in line with the organisation’s plan. Staff supervision systems are good, with supervision records sampled showing six weekly supervision and very good notes with actions for follow up. Staff said that supervision was a helpful process for their ongoing reflection and learning. One staff member said that staff meetings were a useful place to air issues, a positive process with an inclusive agenda. Staff meeting records demonstrated this. Staff said that they were happy working in the home; that it was a well-run place and that they were supported to do their jobs. Some staff highlighted the challenges of recent incidents and said they would like more training to help deal with positively support people with challenging behaviour. Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 22 Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 23 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, 36 and 38 People who use this service experience good quality outcomes. This judgement has been made using available evidence including a visit to this service. The Registered Manager is professional and competent to run the home well in resident’s best interests. The financial interests of service users are safeguarded. The health, safety and welfare of people living in the home and staff are prioritised. EVIDENCE: The Registered Manager has been in that post for over six years. She has achieved the Registered Manager Award and presented as caring and professional in her approach. Staff spoken with said they felt well supported by her and residents also said they felt confident in her capabilities. They all said they trusted and respected the way she runs the home. Residents are involved in running of the home through resident’s meetings and informal consultation. Different types of satisfaction surveys are carried out Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 24 across Servite Homes and at Peregrine House annually to ensure their viewpoints are formally obtained. The Registered Manager said that the main annual survey was being completed at the time of the inspection. We saw the results of a small Servite Homes Service User Satisfaction Survey completed by 32 people across the seven homes in the group. The survey was done in preparation for the main annual survey. Overall, satisfaction was good (69 ) in most areas surveyed. The Registered Manager said that a relatively low number of Peregrine House residents responded to this survey but that the home’s results were the best across the group (the results for Peregrine were also the best in 2006/2007 Annual Survey). However, satisfaction with activities was generally low and this is an area where the organisation is looking for significant improvement from its managers. Changes made in response to resident’s comments in meetings included having some quiet time without television at lunchtime and more regular menu reviews. The home holds a small amount of money for some people. The records were randomly sampled and checked and found to be in order. All health and safety certificates checked were up to date and in order. Infection control policies and procedures are in place. Incident and accident records are completed and actions taken as required. The home sends detailed Regulation Thirty Seven reports regularly to CSCI. Fire protection systems are good. There is a fire risk assessment; regular maintenance of fire equipment; emergency evacuation and fire drills are done regularly. Staff training is ongoing and innovative, with quizzes to check knowledge and specific tests for night staff, who receive training every three months. Emergency lighting was recently replaced. Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 25 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 N/A 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 3 X 3 Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation (17)(3) Requirement Timescale for action 30/10/08 2. OP26 23(2)(p) 3. OP26 23(2)(j) 4. OP30 18(1)(c) The Registered Persons must ensure that Procedures for working with people who have any infectious conditions, like MRSA, should always be clearly documented in each person’s care plan. The Registered Persons must 30/11/08 ensure that The home must improve temperature regulation in the building, which can become too hot. The Registered Persons must 30/11/08 ensure that A problem with the hot water mixer must be resolved to ensure that all residents have access to hot water, including hot water in their rooms. The Registered Persons must 30/11/08 ensure that all staff participate in a mental health training programme to better meet the needs of residents with mental health issues. This should include ongoing training in working with challenging behaviour. Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 27 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. Refer to Standard OP4 OP30 Good Practice Recommendations It is recommended that the home that the service strengthen the mental health plan and provide a copy to the Commission for Social Care Inspection. It is recommended that training for staff infectious diseases be broadened in scope. Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Peregrine House DS0000010734.V364734.R01.S.doc Version 5.2 Page 29 - 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. 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