Inspection on 09/05/06 for Allerton Park

This inspection was carried out on 9th May 2006.

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 01/12/05

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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The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

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 Chris Levi Key Unannounced Inspection 9th May 2006 09:10 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.V292596.R01.S.doc Version 5.1 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.V292596.R01.S.doc Version 5.1 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.V292596.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total of places for dementia care must not exceed 26 Date of last inspection 1st December 2005 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. A copy of the report was displayed in the entrance hall. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection by two inspectors took place over one day, starting at 9.10am and finishing at 6pm. The person in charge of the home was the manager, Ms R Lumbwe. Two senior managers from Park Homes Ltd. were present throughout the inspection. They were given feedback on the findings of the inspection at the end of the visit by the inspectors. The inspectors would like to thank everyone who took the time to talk to us and express their views. This report reflects the preference of people living at Allerton Park to be collectively referred to as residents, rather than service users. Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents, complaints and compliments from service users and relatives. This information was used to plan the inspection visit. During the visit to Allerton Park the inspectors’ case tracked a number of residents. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method the inspectors assessed all twenty-two key standards from the Care Homes for Older People National Minimum Standards, plus other standards relevant to the visit. The inspectors spoke with identified residents and relevant members of the staff team who provide support to the residents. Documentation relating to these residents was looked at. Where possible contact was made with relatives and other external professionals to obtain their opinions about the quality of services provided at the home. Two residents completed a CSCI survey and gave their individual views about living at Allerton Park. Surveys and comment cards for residents and relatives were left at the home. These cards provide people with an opportunity to share their views of the service with the CSCI. Comments received in this way are shared with the provider without revealing the identity of those completing them. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 6 A number of direct quotes from residents, staff and visitors were also included in the report. What the service does well: What has improved since the last inspection? All residents have been issued with contracts giving detail of their terms and conditions of occupancy. The procedure for recruiting staff is thorough, ensuring new staff are suitable to work with vulnerable older people. The new social history plans provide staff with detail about the family, friends and social interests of residents. This enables staff to introduce appropriate social activities for individual residents. The administration and recording of residents’ medication has improved. A permanent manager with dementia care experience has been in post since March 2006. Staff and residents said she was approachable and supportive. Residents said they liked the way the residential lounge had been redesigned. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 7 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.V292596.R01.S.doc Version 5.1 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 Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. People who use the service are able to access clear and accurate information to help them decide whether or not they wish to live in the home. Effective systems are in place to assess service user needs before admission. Residents or their representatives are given written contracts of their terms and conditions of occupancy. The home does not provide intermediate care services. EVIDENCE: The home has up to date written information about services provided at Allerton Park. This document is on display in the entrance hall. It was looked at, and found to contain comprehensive information about services provided by the home, to assist people make a decision about moving to the home. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 10 Since the last inspection all residents or their representatives have been issued with written contracts. This document states the terms and conditions of occupancy and the weekly charges made by the providers. Two signed contracts were seen, and had been signed by relatives on behalf of the resident. A senior manager visits all prospective residents before they move to the home. This allows them the opportunity to assess the needs of the individual, and decide if those needs could be met within the home. Four pre admission assessments were seen. All contained relevant information about the individual needs. This information forms the basis of an initial plan of care when the resident moves to the home. A person was visiting the home for a pre admission visit before deciding if she wanted to move to the home. She said she had enjoyed her visit. The lunch was good, and told the accompanying social worker she would like to move in. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The health and care needs of residents are well met by staff at Allerton Park and external health professionals, to ensure their continued physical wellbeing. Social care needs are also being identified within the care plans, but are not being as well met. Medication for residents is managed in a safe and professional way by staff, to ensure residents receive the correct medication at a time prescribed. It was observed and confirmed by a number of residents, and visitors, that residents are treated with dignity and respect by staff. EVIDENCE: Four care plans were looked at. Each contained relevant up to date easy to follow information. This enables staff to provide appropriate, consistent standards of care and support to individual residents. The plans are reviewed on a monthly basis. The home is to introduce six monthly reviews involving relatives and relevant external professionals who provide care to the resident. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 12 There was evidence that residents or their representatives have signed agreement to the care plan. Information in the plans included mobility assessments, continence assessments, moving and handling guidance and specific tools to assess each individual’s risk of acquiring pressure sores. When a risk to a resident had been identified, staff had assessed the risk and a risk management plan introduced to minimize that risk. Records were seen of visits by external professionals, such as specialist nurses for residents with mental health needs, diabetes and pressure sores. It could be seen from the daily records that referral to other specialists was being carried out swiftly after changes in health had been identified. One resident with a pressure sore had a detailed plan of care to promote healing. It was comprehensive, regularly up dated and involved input by a specialist nurse. In two of the care plans looked at on the nursing unit there were good risk management plans in place, giving guidance to staff in dealing with individuals who may present challenging behaviour. However, a risk identified in another care plan for a resident with challenging behaviour did not have a corresponding plan in place to protect other residents and staff from harm. Residents are weighed on a regular basis. Any resident who has unexplained weight loss should be weighed on a more regular basis, and a plan of care introduced to identify what action is to be taken to minimise the risk of malnutrition. This was seen to be in place for residents on the nursing unit, linked to other documents, such as the daily food and fluid intake charts that the care staff were completing for the nurse in charge. A resident said she was going to see the dentist that morning, because she had problems with her teeth. This was confirmed in the document reviewed. Care plan documentation includes a Social Assessment form, which provides useful details about the person’s past interests and talents, gained through talking with relatives as well as the person themselves. However, more attention needs to be given to developing a corresponding plan that picks up on identified needs, and how these might be addressed by staff at the home. The home has a very comprehensive policy and procedure document identifying all aspects of safe management of drugs. The member of staff administering medicines was aware of the document. The home has changed pharmacist suppliers. A multinational company supply a monthly monitored dosage system for each resident. The company has Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 13 provided training for staff that administer medication, to ensure they are doing so in a safe and timely way. The medication needs of a residential resident were looked at. With the exception of a previous minor recording mistake, the member of staff was observed dispensing and recording medication given to residents in a safe, professional manner. There was written evidence that one resident was partially self- medicating, with assistance from staff. This was confirmed by the resident and staff. The storage of medicines was safe and the medicine room clean and tidy. Throughout the visit staff were observed providing support in a way that maintained the dignity and privacy of the residents, but also with a kindness and sense of humour, indicating they had a good rapport with the residents. . However, staff should now use this knowledge to offer a better social life. One resident said, “ the staff are kind, they really look after me.” Another said, “ I am glad to be here it’s better than being on my own at home.” One person on the nursing unit said, “You can’t grumble about the care, I think people get well looked after here, but it can be a bit intrusive. They could improve how they deal with individuals.” It was evident from observation and discussion during the hours spent on the nursing unit that personal care and attention was given in a very patient and calm wayby the staff, but this was not sufficient to make up for the lack of reassurance and attention to self that this person had identified. Two residents completed the CSCI questionnaires about service standards at Allerton Park. Both made positive comments about staff and the care they receive. One suggested she would like more parties. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Residents are given opportunities to choose how they spend their day and those in the nursing unit are not excluded from social events taking place in the residential unit. However, there is a lack of suitable social activities for all of the residents. Residents are supported and enabled to maintain contact with family, friends and the local community. Food provision is good and meets the needs of the residents. EVIDENCE: Residents confirmed they have a choice of how they spend their day. But many residents were disappointed by the lack of social activities offered at the home. A list of activities was seen in the entrance hall but residents comments included “I am bored – nothing happens here.” When asked how he spent his day, a resident response was “ I waste it.” Residents from both wings were seen enjoying the sunshine in the central garden area during this inspection. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 15 On the nursing unit there was an acknowledgement by senior managers that the staff’s time is very task-orientated at present. This was observed during the day, the staff team being organised into areas of responsibility, such as personal care or managing the dining room. There was little time for social activity outside these tasks. One resident said “they do board games sometimes, but that’s not something I’m really interested in”. It was evident from conversation with residents and managers that there were infrequent opportunities to enjoy individual outings to the theatre or cinema, or to go out for lunch, for example; on the occasions when this had been able to take place, the response from the individual resident had been very positive indeed. In a telephone conversation with a relative after the inspection, the same issue was raised. It is acknowledged that the providers are trying to recruit an activities co-ordinator, with no success to date. However, this post has been vacant for more than six months and is having a negative impact on the social well being of the residents. The providers must address this issue as a matter of urgency. The inspector spoke with a number of visitors to the home. Generally comments were positive. They feel welcomed by staff, are kept informed of changes, and notified of incidents that have occurred. One relative had been notified of an accident. This was confirmed in the accident recording book, and the care plan. The standard for food provision was inspected. One inspector spent most of the day in the nursing unit and was able to observe breakfast and have lunch with the residents. This was followed by a discussion with the chef and the examination of records relating to nutrition within the case-tracking process. The dining room in the nursing unit is equipped with a servery area, including microwave, toaster and vacuum jugs for hot drinks. Some residents were enjoying a cooked breakfast, but the staff could quickly do toast, porridge, etc, as required. The staff confirmed that they have access to food during the night as well, so that residents who are awake at night can be given something to eat. The chef places a high priority on producing good quality meals that the residents will enjoy. He serves the lunchtime meal himself from a hot trolley in the dining room, so that he can monitor likes/dislikes/preferences. The lunchtime meal was of good quality and presented in an appetising way. Residents praised the food and the chef. Most people were being encouraged to eat in the dining room, which had a calm atmosphere. Staff were seen to be patient and attentive to residents that Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 16 needed assistance with their meals, even though they were clearly busy and had a lot of people who needed assisting to eat. One of the residents chosen for case tracking had a nutritional assessment that showed weight loss occurring. Food and fluid charts were in place and staff were monitoring how his appetite and actual food intake was on a daily basis. The GP had been made aware of the potential problem. The menus supplied to CSCI showed a good variety of food across a 4 week cycle; staff confirmed that alternatives were readily available, as stated on the menu, such as omelettes or jacket potatoes. The chef had concerns that new suppliers had been contracted to supply foodstuffs to the home and he was not entirely happy with the quality so far. It was clear from discussion with him that he has high standards and expects to be able to produce high standard meals for the residents. In discussion with senior managers, there was an acknowledgement that there had been some initial hitches and an undertaking to include the catering staff’s views when monitoring quality. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Systems are in place to protect residents from abuse, and encourage them or their relatives to make complaints. EVIDENCE: The home has a complaints procedure displayed in the entrance hall. All complaints are logged by the home and a representative of the organisation decides who will investigate the complaint. A written response to one complaint was seen. The minutes of a multi-agency meeting were awaited by the home. There have been 7 complaints since the last inspection. The outcome of two are not yet known, as they involve external services. The provider must ensure the response times to complaints referred by the CSCI are within the timescale identified. Residents and relatives were aware of whom to complain to if they had concerns. One visitor said a concern raised had been dealt with in a satisfactory way. Staff have received training on adult protection and abuse. One said she had found it very informative. It is positive to note that all ancillary staff have been included in this training, to maximise staff awareness and minimise risks to residents. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 and 26. Identified fire safety maintenance had not been undertaken. This may increase the risk of fire at the home. Some areas of the home especially communal bathrooms and toilets require refurbishing. Residential residents do not have showering facilities. Some areas of the home are not well maintained. Areas of the home show signs of wear and tear and would benefit from a redecoration. Washing facilities in some residents en suite rooms were unsuitable as there was no hot water from the taps of the washbasin. The majority of the home was free from odour and clean. EVIDENCE: Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 19 Areas of the home showed signs of wear and tear and would benefit from a redecoration programme. A senior manager for Park Homes said a programme had been identified following an environment assessment. The decorator said he had painted a corridor on the day of the inspection and was due to come back at a later date to redecorate other areas of the home. The inspector requested that the providers send her a copy of their action plan as a matter of priority in response to the Fire Safety Officers report that identified remedial work in Schedule 1&2 of the report. There was no evidence to indicate the providers have carried out this work. Therefore there maybe a fire safety risk to residents and staff in the building. The five year electrical hard wiring certificate was out of date and the providers must provide evidence that this work has been completed, as a matter of urgency. One of the hot trolleys, used for serving meals, was not working at the time of inspection, therefore hot food was not able to be kept at the right temperature. The kitchenette door in the dementia unit has been fitted with an automatic fire closure mechanism. This would protect residents if a fire were to break out in the kitchenette. A carpet on the first floor was ill fitting and could be the cause of an accident if someone were to trip over it. The communal bathrooms and toilets facilities for residents are, in general, of a poor standard. One on the ground floor had an ill-fitting floor covering and a malodour that would make it very unpleasant to bathe in this room. The residential unit has no shower facility for residents. This results in residents not being able to exercise their choice when bathing. The signs and colour-coded doors on the dementia unit to help residents find their way around the home, are very good, and follow design good practice guidelines. The communal lounges and dining rooms were of a satisfactory standard with furnishing that was domestic and suitable for use by older people. In two residents’ bathrooms no hot water was available from the wash hand basins, and it was noted that a bedside light was not working in the bedroom of one of the people who were case tracked. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 20 Both wings of the house have easy access to the central garden, where residents were enjoying the afternoon sunshine on the day of the visit. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The numbers and skill mix of staff meets residents’ needs. Residents are protected by the home’s recruitment procedures. The home has made a lot of improvements in the area of staff training and while there is still a lot to be done there is a strong commitment to making sure that the staff have the necessary skills and knowledge to meet residents’ needs. EVIDENCE: The staff team includes nurses and trained care staff plus ancillary staff. They were observed carrying out their respective roles in a calm and professional manner. It was particularly noticeable on the nursing wing that staff were good at explaining things to the residents with dementia, reassuring them before interventions were carried out. Most of the staff are from different cultural backgrounds to the residents. The only issue for residents is they sometimes find communicating with staff from other countries difficult. The providers identify opportunities for these staff to study English to improve their communication skills. In discussion with staff they confirmed they had received induction training, safe moving and handling, fire safety training, adult abuse, and medication Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 22 training. It is positive to note that all staff were included in the adult abuse awareness training. Dates for training on care planning and infection control had been identified. The recruitment file of one nurse was looked at. It contained all relevant documentation to demonstrate the home has a robust recruitment procedure. There were interview notes, two references, and confirmation that the nurse was registered to practice from the Nursing and Midwifery Council. The percentage of care staff with NVQ level two was 45 . The home has a programme for NVQ training. On the day of the inspection an NVQ assessor was in the home working with staff from Park Homes. Two of these staff told the inspectors they were enjoying the training. It helped them to understand their roles and responsibilities in providing high standards of care to residents. The inclusion of a service user in some of the in-house staff training sessions is an example of good practice; the resident is able to use his skills as a notetaker and his presence is a good reminder for staff about valuing the individual. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. The management approach encourages residents, relatives and staff to be involved in the day-to-day running of the home and the newly recruited Manager is well supported in her role. Residents’ financial interests are safeguarded. There have been improvements to working practices since the last inspection, however some health and safety shortfalls were identified and these create the opportunity for residents to be placed at risk. The home has good systems to demonstrate ongoing quality review of services provided at the home. Staff have no formal opportunities for one to one supervision. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 24 EVIDENCE: Ms R Lumbwe is the manager of Allerton Park and has been in post for three months. She is a registered nurse, with experience of caring for residents with dementia. As yet, she has no management qualification and has to be registered as manager with the CSCI. Staff and residents said Ms Lumbwe is very approachable and supportive. Park Homes now has an effective senior management structure that provides support and guidance to home managers. Ms Lumbwe said she found this support invaluable. Regular meetings are held for staff, residents and relatives. Proposed changes to existing services are discussed at these meetings to keep everyone informed. Minutes of some of these meetings were seen and confirm the culture of consultation with people involved in the service. The organisation’s quality manager carries out monthly visits. Copies of the findings from the visits are sent to the inspector. They are informative and assist in the continuous evaluation of service standards at the home. The organisation has introduced a quality audit questionnaire, that is sent to residents or their representatives. The Operations Director said he had reviewed the number, and quality of information of completed questionnaires, and decided to introduce this into all Park Homes establishments. Some of the returned questionnaires were seen; these provide the organisation with information to demonstrate a continuous quality management system that is useful and effective in reviewing service standards at the home. Financial records were seen, in respect of the management of individual residents’ personal allowance, where they cannot look after their finances themselves. Good records were in place, which are designed to protect the residents’ interests. It was of concern to the inspector that one to one supervision for staff is not yet in place. It is acknowledged that due to many changes in managers over the past two years, training for supervisors has been difficult to achieve. The providers must now produce a time scaled action plan for implementation of supervision of care staff. The home has been without a handyman for six months. As a consequence a number of health and safety checks had not been completed. This could put residents and staff at risk. The emergency lighting had not been checked and fire safety testing had been sporadic. There was written information to confirm Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 25 fire training had recommenced. The newly recruited handyman was undergoing induction training at another Park Homes establishment. The pre inspection information sent to the inspectors prior to the inspection visit gave dates of maintenance checks carried out during the past year. As identified previously, some maintenance work is not complete, and the providers must rectify this as a priority. Staff said they had received training in safe moving and handling. Staff were observed using hoists and other aids to assist in moving residents in a confident manner. Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 26 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 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 3 2 x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 1 3 2 Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 27 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 OP12 Regulation 16(2)(n) Requirement The providers must introduce a range of social activities appropriate to the needs of the residents. The ill-fitting carpet on the first floor must be repaired. There must be hot water available to residents from the tap of their en-suite facilities. The provider to ensure that redecoration is completed in all remaining bedrooms, communal areas and bathrooms. Timescale for action 30/07/06 2 OP19 23 30/07/06 3 OP19 23 30/07/06 4 OP19 23(4) 5 OP26 16 6 OP31 9 A shower must be installed in the residential unit. The provider must undertake 30/06/06 remedial work identified in Schedule 1& 2 of the fire safety officers report. The overdue fiveyear electrical hard wiring checks must be completed as a matter of priority. The providers to eradicate the 30/07/06 malodour in the residential bathrooms and WC. Previous timescale not met. The manager must commence a 30/08/06 DS0000029131.V292596.R01.S.doc Version 5.1 Page 28 Allerton Park 7 OP36 18 relevant management qualification and apply for registration with the CSCI. The provider must ensure that care staff receive supervision six times a year. All staff must have received the first session by this date. Previous timescale not met. 30/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Allerton Park DS0000029131.V292596.R01.S.doc Version 5.1 Page 29 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.V292596.R01.S.doc Version 5.1 Page 30 - 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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