Inspection on 01/12/05 for Allerton Park

This inspection was carried out on 1st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Allerton Park 29/10/08

Allerton Park 30/04/08

Allerton Park 01/05/07

Allerton Park 09/05/06

Allerton Park 31/08/05

Allerton Park 04/05/05

Allerton Park 14/12/04

Allerton Park 04/10/04

Allerton Park 22/06/04

Allerton Park 01/10/03

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Allerton Park 39-41 Oaks Lane Allerton Bradford BD15 7RT Lead Inspector Susan Knox Announced Inspection 1st December 2005 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 Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 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. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Allerton Park Address 39-41 Oaks Lane Allerton Bradford BD15 7RT 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) 01274 496321 01274 782841 Park Homes UK Ltd Care Home 50 Category(ies) of Dementia (6), Dementia - over 65 years of age registration, with number (26), Old age, not falling within any other of places category (24) Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total of places for dementia care must not exceed 26 Date of last inspection Brief Description of the Service: Allerton Park is part of Park Homes UK Limited, a registered company with several care homes in the area. The home is situated three miles from Bradford city centre and can be accessed by public transport. Parking is provided within the grounds. Allerton Park provides nursing and personal care for a maximum of fifty service users. The building has been divided in order to provide two different types of care in designated areas. The William Forster suite is a 26-bedded unit for dementia with nursing care and the Joseph Cartwright suite is a 24-bedded unit for residential care. Each unit provides accommodation in mainly single room accommodation. All but two bedrooms are equipped with an en-suite toilet. Each unit provides communal rooms of lounge and dining facilities. There is ramped access to the main door and a passenger lift ensures easy access to both floors. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two regulation inspectors carried out this announced inspection over a two-day period between 09.30am and 4.45pm each day. The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard. An acting manager was in post and interviews had been arranged in line with the recruitment of a permanent manager. The inspectors spoke to service users, relatives, and staff including the acting manager, operations director and training and development manager. The majority of the building was inspected. Records were inspected including care plans, assessments, financial records and some health and safety records. A number of comment cards were returned to the CSCI before the inspection from service users and relatives. The majority spoke favourably about the care provided. Feedback was given to the acting manager, operations director and training and development manager at the end of the inspection. What the service does well: What has improved since the last inspection? The use of communal rooms in the dementia suite has improved communal living for the service users. The atmosphere in the dementia suite is calmer and more relaxed. The dementia suite was cleaner, tidier and there was no malodours. Training and support has been given to staff and they were more confident in their roles. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 6 Care plans and staff recruitment procedures continue to improve. 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. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 7 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 Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Good information is readily available about the home and can be made available to suit those with impaired vision. Service users and their families are given an opportunity to look round before deciding whether to move in. EVIDENCE: The statement of purpose has been finalised and a copy was made available to the CSCI. This document, brochures, minutes of meetings and other information about the home, including the last inspection report, are freely available in the main entrance. The detail of the information enables service users and/or relatives to make an informed decision about the home before moving in. Large print documents or audiotapes can be made available on request. Management said that new contracts had not been issued as the document was being amended and would be in place by February 2006. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 9 Relatives said that they had been to look around the home before arranging admission. One said that the family had visited two to three times. They said they were given all the information needed. Care plans seen showed that preadmission assessments had been carried out and copies of assessments by health care professionals are obtained wherever possible. All service users are assessed before admission to the home to make sure that their needs can be met. Pre-admission assessments provided detailed information about the individual’s needs. This home does not provide intermediate care. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Care planning continues to improve and has moved a long way towards being more person centred and individual. Health care needs are met but the procedures for the administration of medication must be reviewed urgently in order to protect service users. Service users are treated with respect and their privacy maintained. EVIDENCE: The inspectors are very aware that the lack of continuity with a registered manager has had an effect on continuity with record keeping. Three sets of care plans were seen on each unit. Action plans were in place for most identified needs. Those that were missing included how to meet an individual’s cultural and religious need. Health care assessments are carried out around physical health care needs but not psychological or mental state care needs. It was noted that some of the assessments were not fully completed and required more detail and type of equipment to use for those with moving and handling needs. The outcomes of these assessments were not always transferred across into care plans, particularly for those with nutritional Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 11 needs. For example, regular weight loss was recorded for one residential client but the nutritional risk assessment stated that weight was steady and no care plan was put in place. There was poor continuity between the assessments, care plans and daily records. Actions identified such as referral to dietician, were not always followed up. The care plan for one did not reflect the needs identified in the pre admission and mental needs assessment. The acting manager said that the care plans reflected current care needs, which were very different to the original assessment of needs. This care plan was under constant review as the individual’s needs were constantly altering and other issues including noncompliance with dietary needs were taken into account. However, there has been a definite improvement in care planning since the last inspection. On the dementia unit they are moving towards being more person centred and individual. Discussions with staff showed that the changes in the lay out of the dementia unit and work allocations combined with good support from the temporary manager and training input has been of benefit. The care plans seen showed that the home contacts health and professionals for advice and support as needed. The care plan for a service user showed that the diabetic nurse had visited that week and put an action plan in place to try and control it. Care planning on the residential unit was to be reveiwed by the acting manager. Discussed with management was the use of medical terms by care staff that may not be fully understood. Discussions were held with a visiting professional who confirmed that staff are helpful and care has improved. Medication policies were in place. Systems were in place to comply with changes in law around the disposal of unwanted drugs from nursing homes. The policy that reflects this change is not formulated yet. Medication administration records (MAR) were reveiwed on both units. On the nursing unit there were gaps in the records for key medication that had not been given the previous day, explanations were given but staff must make sure that records are completed correctly and entries made if drugs are omitted or refused. There is a risk of errors being made if this is not done. This concern was noted in other MAR’s and that the drugs received section were not completed. This means that records of medication received in the home are inaccurate. In addition supplementary drinks were being given to some service users that had not been prescribed them. In one case reductions had been made to the dosage of medication after consultation with the GP. The new regime was documented on the MAR and written up in visiting professional’s record but a new prescription had not yet been obtained. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 12 Qualified nurses administer controlled drugs on both units. On the nursing unit records were accurate but this record on one evening had not been completed on the residential unit. One service user self-administers from own dosage box. Care staff said that they remind GP’s to review medication periodically. The list of specimen signatures and initials of staff trained to administer medication needs up dating to reflect changes in personnel. The method of administering medication was observed to follow good practice. However, other procedures must be improved on the residential unit. Medication that was not part of the MDS was checked. Staff were not recording when two boxes of the same drug were delivered but then administered from either box. Stock medication must be stored elsewhere until required. Staff were recording names across labels for quick identification but this obliterated written instructions and should not happen. Medication for one service user in the form of five tablets had been administered but was not entered into the MAR. Therefore, not only was it not booked in but also staff were giving medication without making a record. Service users said that staff respected their privacy and knocked on their doors before entering. Staff said they were aware of the need and importance of maintaining dignity and respect. Interactions between service users and staff were friendly and appropriate. Staff were knowledgeable about individual health and care needs. One relative in a comment card said ‘he was at all times treated with kindness and respect. He thoroughly enjoyed his stay and the staff and management were wonderful’. Management had introduced a resuscitation policy and records were available in some care documentation where agreements had been reached with service users and relatives. This work was on hold because management were aware of the complexity of the issue and said that the local primary care trust were undertaking some work in order to provide clearer guidance. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15. Activities are provided for residents but a full time activity coordinator would enhance this. Care plans need to include social needs in order to be completely person centred. Service users are provided with a good choice of meals throughout the day taken at a leisurely pace. EVIDENCE: Two out of the nine comment cards expressed reservations about the lack of an occupational therapist. One did not feel there was enough arranged trips out. The home has an activity coordinator who works weekends only and they are actively seeking to recruit a full time worker in this field. On the day of the visit not much was happening in the way of organised social stimulation other than watching the television however, staff were seen spending individual time talking and joking with individuals. Good interactions were observed. Care plans did not show how individual’s social, recreational and leisure needs could be met. A varied programme of organised activities had been organised for over the festive season such as concerts, parties and entertainers. An outing had been made to see Blackpool lights earlier in the year. Mealtimes are recognised as an important social time and it was noted that service users were not rushed. Breakfast was still being served at 10 am. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 14 Lunchtime was observed in both dining rooms. In the dementia unit meals were served in the lounge, dining room or their own bedrooms depending on their individual preferences. The variety of meals and foods served depended on individual needs such as normal, soft diet or pureed. Some service users were given food that was convenient for them to eat. Management recognised that some of those with dementia may fail to recognise the setting of a dining table and provided food according to individual needs. On the residential unit tables were attractively laid with condiments and meals were appropriately served. Staff were observed checking that service users were given a choice. Another explained what and where the plate contained to one with visual impairment. Two comment cards were returned from service users both replied positively about the quality of the food. During discussions with relatives and service users all, apart from one also spoke well about the meals provided in the home. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Information is readily available in the home and as part of a number of documents about how to make a complaint. Staff have received training abuse this would be improved if they were given information about the local authority role in adult protection issues. EVIDENCE: The complaints procedure is prominently displayed in the main reception area and included in the Statement of Purpose. In addition the operations director’s photograph and contact details is also displayed. Regular relative meetings are held. The minutes of these meetings are displayed in the reception area and indicate that frank discussions are held not only about inspection findings but also complaints. In the last twelve months there have been three complaints, one substantiated, one partially substantiated and one pending. These referred to low staffing levels, lack of equipment, poor environment and laundering of clothes. Management stated that 95 of the complaints were responded to in 28 days. Management maintain a proactive approach to complaints. During discussions with staff it was confirmed that most now received training about abuse. In addition it is part of the person centred care training course. Those spoken to would not hesitate to report any concerns to a senior member of staff but they were not aware of local authority adult protection policies and that they could report directly to this body if they wished. Service users said that they felt safe in the home. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 The improvements to the environment in the dementia unit has had a positive effect for service users. Additional lounge space on the residential unit and completion of redecoration in bedrooms and bathrooms would have the same affect. The home was clean with good odour control in the majority of the building. The source of the malodour in bathrooms and WC’s on the residential side must be traced in order to improve the environment for service users. EVIDENCE: The building is divided into two separate units. A full inspection was carried out other than the rooms where service users were ill and the top floor offices. The work started in the dementia unit to provide an environment of benefit to those with dementia such as colours and clear signage has been completed to good effect. Corridors have been painted with murals to create the impression of streets and bedroom doors have been fitted with letterboxes in order to look like house doors. Old newspapers and advertising signs are displayed. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 17 A secure garden has been established since the last inspection with access, one ramped, from both units. Management are aware that more work is required in the garden. The communal rooms in the dementia unit have been rearranged to good effect. Visitors to this unit enter through the dining room rather than a lounge. Cleanliness and odour control was to a good standard. New carpets have been laid in the link corridor and are due to be laid in the new dining room. Management have recognised the importance of staff being able to respond quickly with drinks and snacks to those with dementia. A small kitchen has been provided on the unit. Management were advised to check with the local fire authority if this met with fire safety. The residential lounge is very crowded at times now that the home is fully occupied. Staff have attempted to ensure social interaction by grouping chairs in small numbers. However, crowding is apparent at times. Management were asked to review this and discuss if additional lounge space could be made available. The majority of bedrooms were seen during this inspection. The majority are spacious and all apart from two have an ensuite facility. Many were well decorated and homely with service users possessions displayed. A number were bare looking and need redecoration. Cleanliness and odour control was to a good standard. The home provides a good number of communal bathrooms and toilets. The numbers of bathrooms more than met requirements therefore it was agreed that the large one located on the first floor dementia unit could be altered to a hairdressing salon. Some of the bathrooms were bare looking and would benefit from redecoration. These areas on the residential unit had a malodour that must be eradicated. Other than this odour control was good as was cleanliness. The ancillary areas were clean and tidy. Both kitchen and laundry had paper towels and liquid soap available. New crockery has been provided in the home. The oven keeps breaking down and a new part has been ordered. The laundry had two washers and two dryers. Baskets were identified with room numbers. The laundry staff confirmed that she had attended infection control and moving and handling training. She was aware of the procedures for dealing with foul linen. One relative in a comment card said that sometimes clothes are returned ripped and stains are not completely removed. It was felt that this might occur during weekends when on laundry assistant is available. The home is to recruit a new laundry assistant. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30 Staffing levels have been increased on one unit for the benefit of service users. Levels on the other are considered by management to be sufficient to meet the needs of residential clients. Recruitment procedures have improved greatly but failing to carry out checks before staff start work even for one puts the service users at risk. Staff induction and other training continues to improve and ensures service users are receiving appropriate care. All ancillary staff must be included in statutory training to ensure the safety of all in the home. EVIDENCE: A copy of the staff rota for the week of the inspection was made available. Two comment cards expressed concerns about staffing levels and high turnover. One expressed a slight concern about the recent recruiting of overseas staff with poor language skills although it was said they appeared to be caring. Staffing levels had recently been increased on the nursing unit. For the week of the inspection staffing levels on the residential unit were on the low side, in relation to the numbers accommodated. Management disagreed and felt the numbers of service users with low dependency needs compensated this. Staffing levels will be monitored during further inspections. Staff confirmed that some new staff did have poor communication but this had recently improved. They are attending weekly language classes. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 19 Recruitment files for five staff were seen. Application forms were completed but managers need to ask for full employment history and evidence that employment gaps have been fully discussed. Health questionnaires had been completed. Two written references and criminal bureau record (CRB) checks had been completed including POVA first before the members of staff started work. However, these checks including confirmation of NMC PIN identification had not been carried out for one employee. This last check had been carried out for other qualified staff. Also available were evidence of confirmation and copies of work permits. During discussions with staff they confirmed that they had received a contract of employment and job description. Induction training is given to all staff. Qualified nurses are to be inducted differently by a process more relevant to their roles. The training and development manager has recently completed the Train the Trainer’s course and Adult Protection with the local authority. A training programme is in place and provision has increased. Such as infection control, food hygiene, first aid and also specialist training such as dementia or diabetes. It must be remembered that domestic and maintenance staff require training in moving and handling, health and safety and infection control. Staff felt that the training given has made them better equipped to care for service users and more confident in their roles. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31-38 The present management team are very able and are suitably qualified to ensure the needs of service users are met. The home is actively recruiting a manager in order to provide some stability to the home that would benefit service users and staff. Regular auditing of the home is carried out including health and safety checks for the benefit of service users and staff. Regular supervision of staff is required to ensure that they are able to meet the needs of service users. EVIDENCE: The home is currently operating without a registered manager. A temporary manager has been recruited who is ably qualified to manage. This was confirmed during discussions with service user, staff and relatives and in comment cards. All felt well supported by an approachable management team. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 21 Staff are given clear direction and leadership but the inspectors have concerns about continuity when the acting manager moves on. For example, care planning has suffered because of constant change. The organisation has made repeated efforts to recruit and is actively recruiting once again. The training and development manager regularly audits the home and submits monthly reports to the providers and the CSCI. A random number of questionnaires are sent out monthly to relatives. This information was at head office and could not be seen. One relative confirmed that he attended the regular resident/relative meetings with management present. Policies and procedures have recently been reveiwed and up dated. This work is still to be completed. Staff awareness of policies and procedures is started during induction. Staff confirmed this. Public liability insurance was up to date and displayed as required. The compliance manual includes details of business transactions. A small number of service user’s personal allowances are kept for safekeeping. When monies accumulate the operations director confirmed that this is deposited in individual bank accounts. Receipts and records about these transactions were seen in the home. Supervision has not started for care staff. Training is to be put in place first. It was agreed that all care staff would have received a first supervision session by the 31 March 2006. During discussions with staff it was confirmed that a recent fire drill had occurred. In the last twelve months staff have received fire awareness training. For one individual the Sharps box was kept in the bedroom but the care plan did not refer to this or identify where to access appropriate information on risk assessment and safety measures. In the pre inspection questionnaire completed by the home it was confirmed that the maintenance of services and equipment was up to date apart from gas. This service was due to take place the day of the inspection. Maintenance records were available for inspection. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 22 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 4 2 3 3 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 1 3 3 Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP2 Regulation 5 Requirement The provider to ensure that each service user has a written contract/statement of terms and conditions with the home. The provider to ensure that care plans continue to develop and to include person centred social/life history plans. Ensure that medical terms are not used unless fully understood. Ensure that risk assessments include details about Sharps boxes where these are kept in bedrooms. The provider to ensure that the procedures for administration of medication improves. The provider to ensure that redecoration is completed in all remaining bedrooms and bathrooms The providers to eradicate the malodour in the residential bathrooms and WC. The provider must ensure that recruitment procedures are followed before staff start work. The provider must ensure that care staff receive supervision six DS0000029131.V258488.R01.S.doc Timescale for action 31/03/06 2 OP7 15 31/01/06 3. 4 OP9 OP19 13, 17 23 15/01/06 28/02/06 5 6 7 OP26 OP29 OP36 16 19 18 31/01/06 15/01/06 31/03/05 Allerton Park Version 5.0 Page 24 8 OP38 13 times a year. All staff must have received the first session by this date. The provider must ensure that the local FO is contacted for advice about the new kitchenette. 10/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP20 Good Practice Recommendations The provider to review the lounge space on the residential unit. Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Allerton Park DS0000029131.V258488.R01.S.doc Version 5.0 Page 26 - 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. 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