Southport Care Home rated ‘Inadequate’ – Is the service safe? (CQC)


Photo: Peacehaven Care Home, Roe Lane 

This unannounced inspection of Peacehaven took place on 11 & 12 August 2015.

Located near Southport town centre, Peacehaven provides accommodation and personal care for up to 55 people. Shared areas include two dining rooms, three lounges and a conservatory on the ground floor. A lift is available for access to the upper floors. There is an enclosed garden to the rear of the building and parking to the front. A call system operates throughout the home.

A registered manager was in post. ‘A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run’.

People and relatives we spoke with told us they felt the home was a safe place to live.

The staff we spoke with were aware of what constituted abuse and how to report an alleged incident.

peacehaven-southport-newsSummary of findings

There was a lack of individual assessment around risk of falls and the level of support people required to help mitigate those risks and to protect them from unnecessary harm

People living at the home were not always protected against the risks associated with the use and management of medicines.

Our observations indicated people were supported by sufficient numbers of staff to provide care and support in accordance with individual need.

Recruitment procedures were not robust to ensure staff were suitable to work with vulnerable people. All relevant recruitment checks had not been undertaken prior to staff starting work at the home.

Systems were in place to maintain the safety of the home. This included health and safety checks of the equipment and building.

Staff told us they were supported through induction, regular on-going training, supervision and appraisal. Personnel files however did not always record this information and it was therefore difficult to affirm how staff were supported safely to undertake their job role. A training plan was in place and some staff required ‘refresher’ training in statutory subjects.

Staff told us people who lived at Peacehaven were able to make their own decisions about daily life and support. People’s consent, or relatives if required, was however not always documented in the care files we saw to evidence their inclusion and to ensure the service was working in accordance with the Mental Capacity Act (2005). We observed staff gaining people’s consent before assisting them with personal care or meals, for example.

People’s nutritional needs were monitored by the staff. Menus were available and people’s dietary requirements and preferences were taken into account.

Staff carried out personal care activities in private and people did not have to wait long if they needed support. We found staff support was given in a respectful and caring manner. Staff took time to listen and to respond in a way that the person they engaged with understood.

Care records we looked at showed some input from a variety of health care professionals depending on people’s individual needs. We found however that the staff did not act consistently on care issues identified and had not sought external advice in a timely manner. People were therefore not supported fully to maintain their health and welfare. People were at risk of not receiving the care and support they need as care was not planned effectively

A process was in place for managing complaints. People and relatives told us they had confidence in the manager to investigate any concerns arising.

We received positive feedback about the management and leadership of the home from staff, people who lived at the home and relatives.

Arrangements were in place to seek the opinions of people and their relatives, so they could provide feedback about the home. This included the provision of satisfaction surveys and meetings held at the home.

We found the auditing to be inconsistent. Many of the concerns found by us in respect of staff support and staff recruitment, incidents/falls risks, care planning and safe administration of medicines had not been picked up. Therefore the current system to monitor the quality and safety of the service was not effective and had the potential to place people at risk.

You can see what action we told the provider to take at the back of the full version of this report.


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