CARE HOMES FOR OLDER PEOPLE
Allerton Park 39-41 Oaks Lane Allerton Bradford BD15 7RT Lead Inspector
Chris Levi Key Unannounced Inspection 09:00 1st May 2007 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.V331471.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. Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 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 *** Post Vacant *** 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.V331471.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The total of places for dementia care must not exceed 26 Date of last inspection 9th May 2006 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. The current weekly fees charged by the providers is £318- £623. Additional charges are made for hairdressing, private chiropody and newspapers. This information was provided to the Commission for Social Care Inspection in April 2006. The contents of Inspection reports are discussed at staff, relative and residents meetings. Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Evidence used to compile this report has included: Information requested from the providers in a Pre-Inspection Questionnaire A review of information about the home held by the Commission for Social Care Inspection. This included looking at the number of reported accidents, complaints and compliments from residents and relatives. This information was used to plan the inspection visit. The written and verbal opinions of residents and relatives who live and visit Allerton Park. The providers were not notified of this inspection in advance. This enabled the inspector to observe how the home is run on a day-to-day basis, without any changes being made to the usual routines of residents and staff. The visit started at 9am finishing at 5.30pm. At 11.30am to 3.30pm a second inspector visited the home to undertake an indepth observations of a small number of residents with dementia, to measure their well being. The findings were shared with the providers and are included within this report. Before the observation took place the process was explained to the manager of the service. Due to the poor staffing levels in the home he was not able to inform all the staff in the unit as to what was going to happen over the course of the two-hour observation. He spent two hours observing staff interaction, the engagement and state of being of five residents with dementia. Some of the results and comments are included in the report. The person in charge of the home was the Manager Ms R Lumbwe, who, with Mr J Sykes, the Operations Director of Park Homes were made aware of the findings at the end of the inspection. Most of the day was spent talking to residents, relatives, management and staff, to find out what it is like to live, work and visit Allerton Park. One of ten residents survey forms were returned before the visit. The comments were positive about the services at the home. Five relatives comment cards were received, again they indicated that relatives and friends are satisfied with the standards at Allerton Park. A number of external health professionals were contacted by telephone. They raised a number of issues where they though the service could improve, and
Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 6 considered services provided to residents adequate. This information was shared with the providers. A general observation by all those providing information was, there was not enough staff on duty. On the day of the visit the home was two members of staff short, one had phoned in sick, another had accompanied a resident to hospital as an emergency admission. This shortage resulted in a chaotic, task driven service by staff during the morning on the dementia unit. What the service does well: What has improved since the last inspection? What they could do better:
Staff should be appropriately deployed to meet the needs of residents in a way that maintains their dignity. There were a number of incidents observed and discussed at the end of the inspection that compromised resident dignity. One example seen was, the majority of residents on the dementia unit were not wearing any footwear. This could result in an increase of falls and injury to a resident. Staff appeared not to consider appropriate footwear for residents important, indicating further training is necessary.
Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 7 The current system of ordering and administration of resident medication should be reviewed. Errors in the ordering system, and delays in receiving some medication from the pharmacist results in residents not receiving their medicine promptly. The organisations decision not to distribute medication during meal times is positive. However, it does result in some residents receiving medication much later than prescribed and may have a negative effect on the resident’s health. Nurses employed by the home must understand and follow the nursing principles identified by the organisation, and other external health professionals, to ensure residents receive the best nursing care possible to maintain their general health. The Manager must pursue her application for registered manager with the Commission for Social Care Inspection as soon as possible. She has been in post for more than a year and is required to demonstrate her suitability as manager to the CSCI who regulate the home. Due to the temporary redeployment of the organisations training manager, staff training has been delayed. Staff have received safe moving and handling training to ensure they know how to move residents without injury. However, in discussion with staff and training records looked at, all other training has been put on hold. Observations were made that staff need training in infection control to minimise the risk of cross infection and risks to resident and staff health. Environmental issues that require attention include the providers need to urgently instruct external electrical professionals to undertake the examination of the homes electrical hard wiring. The previous certificate is two years out of date and could result in putting resident and staff at risk from fire. Urgent attention is also required to a number of fire doors in the building that are faulty and may not protect residents in the case of a fire. It is noted that the homes health & safety representative brought this to the attention of the owners, Park Homes Limited, and there has been a failure by them to rectify this risk. The flooring on the ground floor near the small lounge is uneven and presents a risk of falls for residents. The hot water discharging from the hot taps in residents’ rooms and the bathrooms is above safe levels, and may put residents at risk from scalds. The home has one hot trolley out of action, this results in food service to residents being delayed. Most bedrooms visited were of a satisfactory standard. However, two were identified as needing a new carpet or alternative floor covering and one
Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 8 bathroom had been without floor covering for more than three months. This is a health and safety hazard for the resident as the flooring is uneven. Finally, resident’s dignity is compromised because none of the communal toilets on the ground floor have working locks. 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. Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 9 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.V331471.R01.S.doc Version 5.2 Page 10 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): 1, 2 and 3. People who use the service experience good quality outcomes in this area. We made this judgement using a range of evidence, including a visit to the service. Information is available to people about services provided at Allerton Park, to help them decide if they wish to move to the home. Effective systems are in place to assess prospective service user needs before admission, to ensure staff and facilities within the home can meet their needs. Contracts provided to all residents identify their rights and responsibilities during their stay at Allerton Park. EVIDENCE: Written information is available for people considering living at Allerton Park. It informs them of the services provided and charges made. The organisation also has copies of this information and Braille should it be needed.
Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 11 The home has a procedure for assessing the needs of prospect residents. All prospective residents are invited to visit the home before a decision is made to move in. However, many of the residents with dementia are not capable of making such decisions, and are made on their behalf by a relative or social worker. A senior member of the staff team undertakes a written pre admission assessment, to ensure that staff can meet the needs of the resident once they move to the home. This documentation was looked at and found to be relevant and comprehensive to the residents needs. It is positive to note that the home has a policy to reassess all residents admitted to hospital before they return to the home, to ensure any change in needs can still be met. However, one resident returned without this assessment, which resulted in an emergency readmission to hospital. Less than two days after their discharge by the hospital, resulting in distress for both the resident and family. Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 12 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 the service experience adequate quality outcomes in this area. We made this judgement using a range of evidence, including a visit to the service. The health, personal and social needs of residents are not always met in a way that maintains their dignity and independence. EVIDENCE: All residents’ care needs are recorded in a care plan. This information is used by staff to ensure they are providing the correct levels of care, in a way that has been discussed and agreed with the resident or their family. One plan was looked at in detail. Information was comprehensive, identifying the complex needs of the resident. However, the reviews of each plan of care did not always accurately reflect the changing needs of the resident, who was cared for in bed. This could result in an inconsistent approach by staff, when providing for their care and nursing needs. An incident where a nurse did not follow the homes procedure when dealing with an injury, sustained by a resident following a fall was of concern. The
Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 13 dementia unit has trained nurses to provide for the nursing needs of residents on the dementia unit. They must be competent to provide this care and follow the advise of external health professionals relating to the most appropriate treatment to promote a speedy recovery for residents. Issues regarding delays in receiving medication from the pharmacists were identified. This has resulted in residents not receiving medication in a timely way and could hinder their recovery. The organisation’s decision that residents should not be given medication during mealtimes is positive regarding dignity and privacy. However, it results in some residents not receiving their medication at a time prescribed by the doctor. It is recommended that a review of administering medication by nurses takes place to maintain dignity, but minimises the risks to residents of taking medication at the wrong time. Generally, staff were observed working hard to meet the needs of residents, but in the morning, because of the shortage of staff this resulted in a task led approach with little evidence of a person centred approach, which promotes the wellbeing of people with dementia. For those residents cared for in their room, it is recommended that recording of information be held within the room, with staff encouraged to record when and why they are visiting the resident. This will reduce the risk of isolation. There were a number of incidents observed and discussed at the end of the inspection that compromised resident dignity. One example seen was, the majority of residents on the dementia unit were not wearing any footwear. This could result in an increase in falls and injury to a resident. Staff appeared not to consider appropriate footwear for residents important, indicating further training is necessary. The lack of privacy and dignity for residents, because toilet doors do not lock, is unacceptable. The second inspector shared observations where dignity was promoted and others that were not, with the manager. However, incidents where resident’s dignity was promoted was not consistent amongst all the staff, indicating a training need and a need for leadership and direction from the senior members of staff. Allerton Park DS0000029131.V331471.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 the service experience adequate quality outcomes in this area. We made this judgement using a range of evidence, including a visit to the service. Residents living on the residential unit spend their day as they choose, seeing whom they choose, when they choose. However, the choices for residents living on the dementia unit are more restrictive. EVIDENCE: The appointment of a full time social activities organiser has brought positive benefits to all the residents at Allerton Park. She has established the social interests of individual residents, and works hard to ensure time is spent appropriately with individuals to improve their levels of concentration, interest in daily life skills, and social activities. She has been funded by the local PCT to undertake a qualification that will allow her to introduce appropriate exercises for residents to maintain their mobility. Written records were seen of the daily events she has participated in with residents. Observations indicated she knew the residents well, and had excellent rapport with them all. It was noted that care staff persuaded residents with dementia from accessing the enclosed garden area, despite it being a lovely sunny day. Their reason
Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 15 was that residents try to climb over the fence, and there was not enough staff to observe the garden area. Residents were encouraged to sit in the lounge, where there was no stimulation apart from the television. During the day a clothes party was held in the residential unit where residents were able to buy new clothes if they wished. The second inspector undertaking the in-depth study of five residents observed the following incidents, they include good and poor care practice. • There were some positive staff interactions, especially around meal times. Staff were kind and pleasant and got down to the residents eye level when they talked to them. One resident was asked whether they wanted to sit in the lounge or stay were they were. Some residents showed appreciation of the music when it was on and were seen to tap their feet and hands to the music. However, the music was on for the two hours of the observation and the residents soon became oblivious to it. The interaction with residents in the lounge area was poor. It was mixed as to how staff communicated with residents when they entered the room. When they did come in it was mostly to carry out some personal care. Other residents in the room received no interaction. Residents appeared to be quite thirsty. Two that were offered a drink in the lounge drank it all in one go, which strongly indicated thirst. One carer came into the room and asked one resident whether they would like a cup of tea. She did not ask the other three residents in the room. She never returned with the drink. • • • • One resident missed her lunch as no one remembered to go back to the lounge to assist her with it. She was asked whether she had had her dinner but was not able to answer The staff did not appropriately deal with confrontation and agitation. It was quite chaotic at times. There appeared to be a lack of understanding of the dementia condition and how to manage this as a specialist carer. Visitor’s comments included “ The manager and all the staff make me welcome when I visit.” “The staff ring me if my husband has a fall.” Visitors and families are encouraged to participate in surveys about their views of the home. Residents were generally positive about the food served at the home. One resident who did not like the dish of the day was given an omelette as an alternative. The home has only one hot trolley and this is affecting the service
Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 16 of meals within the two units a replacement for the broken trolley would improve service and ensure all residents receive food at the correct temperature. The kitchen in the basement was clean, but the cooker needs to be deep cleaned. Although a notice outside the kitchen informed staff to wear protective clothing when entering the kitchen, there were no aprons available and one staff member was not wearing protective clothing, thus increasing the risk of cross contamination. An Environmental Health Inspection in August 2006 identified a satisfactory inspection, with a requirement to purchase a new food temperature probe to ensure food was cooked and served at the correct temperature. Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 17 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 the service experience adequate quality outcomes in this area. We made this judgement using a range of evidence, including a visit to the service. Residents and relatives can complain, and all staff are trained to ensure they understand adult abuse, to protect residents at the home. EVIDENCE: The home has a complaints procedure that is displayed in the entrance hall. Relatives said they felt confident that if they had concerns they would approach the manager. The home has had a number of complaints, some involving the safeguarding of adults. Those relevant have been referred to appropriate external agencies to investigate. The organisation has developed an open and thorough approach to investigating complaints. Most are resolved within the agreed timescale of 28days. However 30 go beyond this timescale. This has a negative effect on other agencies that are awaiting outcomes to respond to complainant. There has been a number of referrals relating to safeguarding vulnerable adults. Some of these have been referred by the home and relate to incidents between residents. The training plan for staff indicated that most staff have attended training on safeguarding vulnerable adults. Two staff confirmed they would report to the
Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 18 manager any incidents that caused them concern regarding protecting vulnerable older people. Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 19 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, 20, 21, 24 and 26. People who use the service experience adequate quality outcomes in this area. We made this judgement using a range of evidence, including a visit to the service. Residents maybe at risk from harm because areas of the home are not safely maintained. EVIDENCE: Environmental issues that require attention include the providers must urgently instruct external electrical professionals to undertake the examination of the homes electrical hard wiring. The previous certificate is two years out of date and could result in putting residents and staff at risk from a fire. Urgent attention is also required to a number of fire doors in the building that are faulty and may not protect residents in the case of a fire. It is noted that
Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 20 the homes health & safety representative brought this to the attention of the company and there has been a failure by them to rectify this risk. The flooring on the ground floor near the small lounge is uneven and presents a risk of falls for residents. The hot water discharging from the hot taps in resident’s rooms and the bathrooms is above safe levels, and may put resident at risk from scalds. Most bedrooms visited were of a satisfactory standard. However, two were identified as needing a new carpet or alternative floor covering and one bathroom had been without floor covering for more than three months. This is a health and safety hazard for the resident as the flooring is uneven. Resident’s dignity is compromised because none of the communal toilets on the ground floor have working locks. There were a number of toilet doors painted different colours to help those residents with dementia find their way to a toilet on their own. Generally, the home was clean, but there was an odour of urine in the residents lounge, making it an unpleasant place to sit. Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 21 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 the service experience adequate quality outcomes in this area. We made this judgement using a range of evidence, including a visit to the service. The procedures for the recruitment of staff are thorough, and ensure that staff are safe to work with vulnerable adults. Staff training and deployment must be improved to ensure a consistent, effective approach when providing care to the people living in the home. EVIDENCE: The recruitment file of one member of staff was looked at. It contained all relevant information, with evidence that references and police checks had been completed before she commenced employment, to ensure she was fit to work with vulnerable adults. Staff should be appropriately deployed to meet the needs of residents in a way that maintains their dignity. There were a number of incidents observed and discussed at the end of the inspection that compromised resident dignity. One example seen was, the majority of residents on the dementia unit were not wearing any footwear. This could result in an increase of falls and injury to a resident. Staff appeared not to consider appropriate footwear for residents important, indicating further training is necessary. A general observation was, there was not enough staff on duty. On the day of the visit the home was two members of staff short. One had phoned in sick,
Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 22 another had accompanied a resident to hospital, as an emergency admission. This shortage resulted in a chaotic, task driven service by staff during the morning, on the dementia unit. Due to the temporary redeployment of the organisations training manager, staff training has been delayed. Staff have received safe moving and handling training to ensure they know how to move residents without injury. However, in discussion with staff and training records looked at, all other training has been put on hold. Observations were made that staff should be trained in infection control, to minimise the risk of cross infection and risks to resident and staff health. Five of the twenty care staff have achieved NVQ level two, this is a low number as a target figure is 50 . Three staff members are trained in first aid. The home has a multicultural staffing group, who appear to understand the needs of the residents, none of whom are from a multicultural background. Communication and cultural understanding did not create problems, generally there was a positive social rapport between residents and staff, but it was task focussed. Allerton Park DS0000029131.V331471.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, 32, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. We made this judgement using a range of evidence, including a visit to the service. The management of home has improved , but further improvements are needed to achieve good outcomes for residents, especially in areas where health and safety issues are identified and not acted upon the organisation. EVIDENCE: Ms R Lumbwe, the Manager has been in post for more than a year. She is a registered nurse, with experience of managing services for people with dementia. She is currently undertaking a management qualification which should develop and complement her existing skills and knowledge to manage a large diverse service.
Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 24 She has yet to be registered with the Commission for Social Care Inspection to demonstrate her suitability as manager to the CSCI who regulate the home. It is acknowledged that time management has been an issue, as she has no administrator, and only recently recruited a deputy manager. Without exception, those residents, relatives, staff and external professionals visiting the home I consulted, complimented Ms Lumbwe for her skills as an effective manager. She is considered very approachable and supportive, with a focus to improve standards of care to residents who live at Allerton Park. Park Homes Limited has introduced an excellent quality monitoring system that involves relatives and residents, and a detailed internal quarterly audit of the services provided. The score for the last quarter was 61 , resulting in the service being judged as adequate by the providers. This information forms the basis for improvement of services to residents living at Allerton Park. Residents’ monies held at the home is managed in a safe way. There is evidence as to who, and how residents’ monies is spent. Relatives are encouraged to manage the financial affairs of any resident unable to manage their own money. Staff receive one to one supervisions. Evidence of this was confirmed in conversation with a member of the care team. A senior member of the home has responsibility for the health and safety checks. These checks need to be undertaken on a regular basis to ensure the safety of residents and staff within the building. There was evidence this role has been well developed. For example there were risk assessments for staff that were pregnant, to ensure they worked safely whilst in the home. For reasons that are unclear, identified shortfalls in safety brought to the provider’s attention had not been addressed, leaving residents and staff at risk. Records identifying fire doors were not working correctly evidenced this. Allerton Park DS0000029131.V331471.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
ENVIRONMENT CHOICE OF HOME Standard No Score 1 2 3 4 5 6 Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 x x n/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 2 2 x x 2 x 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 4 x 3 3 x 2
Version 5.2 Page 26 Allerton Park DS0000029131.V331471.R01.S.doc 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 OP8 Regulation 18 (1) 18 Requirement Staff must be competent and sufficient in number to provide appropriate levels of care to maintain the health and well being of residents. This includes the nursing and personal care needs. They should receive training in infection control and promoting dignity for residents and other training outlined by the Skill for Care Council . Residents medicines must be available when prescribed by the GP and administered at times in accordance with the GP instructions, to minimise the risk of residents health being affected because they have not received medication as instructed. The home must ensure that food served is maintained at a temperature that minimises the risk of food becoming contaminated and causing illness. The overdue five-year electrical hard wiring checks must be completed as a matter of
DS0000029131.V331471.R01.S.doc Timescale for action 30/07/07 2 OP9 13 (2) 30/07/07 3 OP15 16 30/07/07 4. OP19 OP38 23(4) 30/06/07 Allerton Park Version 5.2 Page 27 5. OP19 OP38 OP10 OP38 23 (1) 6 12 priority. (Previous timescale not met 30/06/06) Ill fitting fire doors must be repaired or replaced to minimise the risk to residents and staff in the event of a fire. Communal toilets must be fitted with locks to maintain residents dignity. 30/05/07 30/06/07 7 OP19 OP38 13(4) Replacement flooring is necessary in a residents room. Also floor covering in a residents bathroom is required as it is currently a health & safety hazard. The temperature of hot water 30/06/07 from residents’ handbasins and communal toilets and baths must be brought within safe limits to avoid any risks of scalding. The uneven flooring on the ground floor must be resolved as it is health & Safety hazard as residents may trip and fall. The manager must apply for registration with the CSCI. ( previous timescale not met 30.08.06) 8. OP31 9 30/06/07 Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 28 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 OP10 Good Practice Recommendations For those residents cared for in their room it is recommended that recording of information be held within the room, with staff encouraged to record when and why they are visiting the resident .This will reduce the risk of isolation. Allerton Park DS0000029131.V331471.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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
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