Inspection on 10/06/09 for Headingley Park

This inspection was carried out on 10th June 2009.

CQC found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Headingley Park 11/12/08

Headingley Park 19/05/08

Similar services:

Elmleigh Convent

Eastfield Farm Residential Home Limited

Cranwell Court Care Home

Fairview

Cottingham Hall

Cranmer Scheme

Fairburn Mews

Claremont House

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Edlington Park Care Home Headingley Way Edlington Doncaster DN12 1SB Lead Inspector Sarah Powell Key Unannounced Inspection 10 & 18th June 2009 09:30 th DS0000070011.V376150.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Edlington Park Care Home Address Headingley Way Edlington Doncaster DN12 1SB 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) 01709 862542 01709 869200 edlington@mimosahealthcare.com None Mimosa Healthcare (No4) Limited Post Vacant Care Home 40 Category(ies) of Dementia (40) registration, with number of places Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either, whose primary care needs on admission to the home are within the following cagtegory: Dementia - Code DE The maximum number of service users who can be accommodated is: 40 11th December 2008 2. Date of last inspection Brief Description of the Service: Edlington Park is a care home for older people consisting of two units; both units provide care for people with dementia. The home is in Edlington village close to local shops and amenities. All the bedrooms are single with 30 of the rooms having en-suite facilities. There are adequate communal baths and shower facilities. There are dining rooms and lounge areas on each unit. The home also has a large conservatory. There are gardens accessible to all people. The fees at Edlington Park at the time of the inspection were £395 to £410. These fee charges only applied at the time of inspection, more up to date information may be obtained from the home. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been revised or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. This was an unannounced visit, which took place on 10th and 18th June 2009 the first day commenced at 09:30 and finished at 15:00 hours. The second day commenced at 09:30 and finished at 16:40 hours. On the first day as part of the visit we spent 2 hours in the lounge watching what was happening. This showed what life was like for people using the service. A random visit also took place on 11th March and 30th March 2009 to check compliance with the statutory requirement notices on the second visit the notices had been complied with. A visit was also carried out by the pharmacy inspector on 11th March 2009. This visit identified there were improved systems in place for the ordering, administration, recording and storage of medicines and all the outstanding requirements and recommendations had been complied with. This inspection visit included talking with people living at the home, a number of professionals, the acting manager and seven staff. During the visit we also walked round the building to gain an overview of the facilities. We also checked a number of records. The acting manager had completed an annual quality assurance assessment (AQAA). The AQAA focuses on how well outcomes are being met for the people using the service. It also gives us some numerical information about the service. Full feed back was given to the acting manager during the visits and at the end of the second day. The area manager was also given feedback. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 6 What the service does well: The staff understood people’s needs interactions observed were very good, people told us staff were lovely and looked after them well. The improvements since the last inspection show where the service does well and the acting manger told us she intended to continue to improve the service, ensuring all peoples needs were met. What has improved since the last inspection? What they could do better: The environment remains poor with many bedroom, communal area, bathrooms and toilets requiring redecoration and new floor coverings. The acting manager told us she had implemented a maintenance and renewal plan and when the number of residents increased she was able to employ Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 7 contract decorators to re decorate the communal areas. The maintenance person employed by the company was redecorating bedrooms. This will ensure people live in a well maintained environment. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in the home had their needs assessed prior to moving into the home. EVIDENCE: Suitably qualified staff carried out the pre admission assessments on people who wanted to move into the home. The assessments were very detailed with all peoples needs identified, ensuring that the home could meet their needs before a place was offered to them. The home does not offer intermediate care so standard 6 does not apply. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 10 Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person in the home had a plan of care with clearly identified needs, these were met, and people were treated with respect. Medication procedures protected people. EVIDENCE: Two plans of care were looked at in detail. The care plans had been rewritten since the last key inspection and were very good. The plans had identified the needs of the people with good recordings of the measures to take to meet their needs. The plans were regularly reviewed; people and their relatives were Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 12 involved in this process. This ensured their views were listened to and their needs met. The acting manager had also started to include evidence that the mental capacity act had been taken into consideration, with regard to peoples capacity and choices this ensured peoples needs were identified and met allowing them to make choices and decisions regarding their care. All health care needs were met and regular input from health care professionals was obtained. Their advice was followed and well documented in the plans ensuring the wellbeing of the people who lived in the home. People were treated with respect and privacy and dignity upheld. During the visit we carried out a detailed observation and we observed staff interacting very well with people. One person told us, “The staff are lovely and look after me very well”. We spoke to relatives who all praised the staff and the care provided one relative told us, “The staff are good they look after people very well, are always approachable and keep me informed of any changes”. Medication policies and procedures safeguarded the people. Medication was well documented on receipt, administration and return. All staff who administer medication regularly receive medication training and undergo competency assessments to ensue people are protected. The manager regularly audits medication to ensure people’s needs are met. However there were no staff working nights that could administer medication, an on call system was used, this did not always meet peoples needs. The acting manager since the visit has allocated four nights with a senior carer and is recruiting a senior carer to work nights, this ensures peoples needs will be met. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Most people exercised choice and control over their daily lives and activities ensuring their needs were met. EVIDENCE: An activities co-ordinator was employed for 15 hours each week. Activities were varied and changed depending on the choices of the people who attended on the day. The activity co-ordinator also told us that one to one activities were starting to be provided for people who were unable to join in group activities, or for people who preferred one to one activities. This will ensure all people’s needs are met. Records were kept of activities and who took part, this showed people were joining in and enjoying the activities provided. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 14 On the day of our first visit staff had taken a number of residents out on a trip, some staff had given there own time to accompany the residents. When they returned the people told us they had had a lovely time. The week’s activities were displayed on the board in each unit, to keep people informed of what was happening. Although the activities co-ordinator only worked limited hours, when she was not in the home the general assistants provided some activities. The acting manager told us when more residents were in Edlington Park the hours would be increased to ensure all peoples recreational needs were met. The people and their relatives we spoke to all said that contact with family, friends and the local community were encouraged by the staff and relatives were always made welcome. The provision of food had greatly improved since the last key inspection, plentiful supplies of food were available in the store rooms, food was provided that was suitable for the client group, advice from a dietician had been followed this ensured peoples needs were met. A varied, balanced and wholesome diet was provided for the people with good choices available. We observed a meal, which was well presented, there was good communication to the people from staff when it was served, seconds were offered, people were asked if they were finished before plates were taken and a choice of drinks were also offered. This ensured peoples needs and choices were met. People who required assistance were given it discretely and sensitively to ensure there needs were met. One person told us, “The meals are lovely, I always enjoy them”. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who lived in the home were listened to and protected. EVIDENCE: There was a comprehensive complaints procedure, which was clearly displayed, in the entrance hall. All people we spoke to were aware of the procedure and told us they would either speak directly with the acting manager or staff. The manager had received two complaints. Good records were kept of the investigations and outcomes. This showed they had been fully investigated, acted on, taken seriously and resolved. All staff had received training in adult protection; all staff we spoke to had a good knowledge of the procedures and what to do should an incident occur. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 16 Staff were also aware of the whistle blowing policy, which safeguards people in the home. The manager also had a copy of the local authority safeguarding policy. This ensured the staff were aware of the local procedure. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of cleanliness was good however the general environment required redecoration, new carpets and floor coverings. EVIDENCE: Many environmental standards still required attention. Floor coverings in bathrooms, toilets, and some bedrooms and corridors were badly stained and marked. Some chairs, tables and bedroom furniture remained damaged and Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 18 required repairing or replacing. The environment was still not well maintained for the people who lived there. However the acting manager had completed an action plan, which she showed us, it detailed that when occupancy reached 30 a decorator would be employed to redecorate all corridors and communal areas and then new floor covering would be purchased. The maintenance person would continue to redecorate bedrooms as required. The cleanliness was good throughout the home. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were appropriately trained, the recruitment procedures were robust ensuring people were in safe hands at all times, had their needs met and were protected. EVIDENCE: The staff on duty met people’s needs and the skill mix was appropriate to the assessed needs of people. A new staffing structure was to be implemented to ensure the acting manager was supported and people’s needs were met. Mandatory training was mostly up to date and there was clear evidence that the acting manager was maintaining this for the majority of staff and updates were also provided. The acting manager had worked very hard on the training over the last six months to ensure staff were appropriately trained to meet peoples needs. There were some courses which staff required to update, that had either expired or were due to expire, the acting manager had identified Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 20 who required updates and was arranging the training to ensure staff were appropriately trained. All staff completed induction training and two new starters were due to start, although they had completed a basic induction from the acting manager. NVQ training was ongoing to ensure people were in safe hands at all times. The acting manager had also enrolled the kitchen staff on NVQ level 2 in cooking and hospitality. An NVQ in activities is also being considered for the activities co-ordinator. The acting manager is also looking at providing more courses specifically relating to conditions that affect the elderly, this will enable staff to be aware of different conditions and how to manage them and meet peoples needs A thorough recruitment procedure was in place, we looked at one staff file, a new starter that the acting manager had appointed, the procedure had been followed and all the required information and appropriate checks had been obtained. This ensured people were Protected. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management and administration safeguards people, good health and safety policies and procedures were in place ensuring the safety of people in the home. EVIDENCE: Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 22 The acting manager had been in post since December 2008, she had previously been the deputy for a year and has worked in care settings for 9 years. She has successfully completed an NVQ level 3 in health and social care and is due to start the NVQ level 4 in care and management. She has also submitted an application to the Care Quality Commission to become the registered manager and is awaiting a date for interview. In the last six months the acting managers’ competencies and management ability have considerably improved, she is able to discharge her responsibilities fully. The ethos of the home had changed completely it was open, positive and inclusive. Staff told us, “It was a much better place to work, the manager had worked very hard to improve things and it was working”. Quality monitoring was carried out; the manager did regular audits and had regularly sent quality-monitoring questionnaires to people in the home and their relatives. This ensured the home was run in the best interests of the people who lived there. The home managed some people’s finances and personal money. We checked two records with the administrator, which were correct. The manager told us all records were maintained and all receipts were kept, ensuring peoples financial interests were safeguarded. The home had a comprehensive health and safety policy. We were able to evidence that regular maintenance of equipment and systems was carried out. Risk assessments were carried out on all safe-working practices, regular audits were carried out on the building and all accidents were properly recorded and reported ensuring people in the home were safeguarded. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X 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 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Yes Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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 OP19 Regulation 16 Requirement The redecoration programme must continue to that people are provided with a well-maintained environment. (Revised requirement outstanding from 01/03/08 and 1/4/09) Timescale for action 01/11/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP12 OP30 Good Practice Recommendations The additional ten hours for an activity co-ordinator should be filled to ensure all people’s needs are met. Continue to provide staff with appropriate training in the conditions and diseases associated with old age. Ensure that staff collectively have the skills to deliver the care, which the home offers to provide. Provide staff who are able to administer medication on night duty by continuing to recruit. 3. OP9 Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 Page 25 Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Edlington Park Care Home DS0000070011.V376150.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!