Inspection on 20/08/07 for Fallings Park Lodge

This inspection was carried out on 20th August 2007.

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

Fallings Park Lodge 26/02/08

Fallings Park Lodge 04/12/07

Fallings Park Lodge 20/06/07

Fallings Park Lodge 16/01/07

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Fallings Park Lodge 99 Old fallings Lane Fallings Park Wolverhampton West Midlands WV10 8BJ Lead Inspector Rosalind Dennis Key Unannounced Inspection 20th August 2007 09:00 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 Fallings Park Lodge DS0000068603.V348862.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. Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fallings Park Lodge Address 99 Old fallings Lane Fallings Park Wolverhampton West Midlands WV10 8BJ 01902 722700 01902 722700 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) Aplin Care Homes Ltd Yvonne Margaret Lavender Care Home 48 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (35) of places Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. In the OP category Females 60 years and above and males 65 years and above The home should only accommodate up to 13 service users with dementia. Up to seven service users aged 55 years plus, other service users must be over 60 years. The Second floor lounge and bedrooms are used for the thirteen service users with dementia. 20th June 2007 Date of last inspection Brief Description of the Service: Fallings Park Lodge is a new purpose built care home situated in the residential area of Fallings Park and is close to local shops and amenities. The home has three floors with wheelchair and disabled access throughout. There are 48 bedrooms all of which have en-suite and a modern nurse call system. There are five communal lounges each incorporating dining facilities for the residents. The top floor has thirteen rooms, which are registered for use by residents with dementia. The home has extensive gardens and grounds, which has raised flower beds and there is car parking at the front of the building. At this inspection weekly fees are confirmed as £347 per week. Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by two inspectors over a period of around 7 hours. The purpose of this inspection was to look at what improvements had taken place since the last key inspection in June 2007 and to assess all ‘key’ standards -that is those areas of service delivery that are considered essential to the running of a care home. Time was spent speaking with people living at the home, observing staff working, speaking with staff and the management team and looking at a range of documentation. People living at the home spoke positively about the care they receive and people appeared content and well cared for. Since the last inspection the provider has appointed Susan Swift as Deputy Manager and the new “Responsible Individual” for the service. This arrangement is of some concern as there is the potential for tensions or confusions with the line management role between manager and deputy - i.e. the supervisory and disciplinary role, and the main role of the responsible individual, which is to supervise the management of the service. In some ways this situation means that the people involved are managing each other. The manager, Yvonne Lavender, and Susan Swift were on duty at the time of the inspection and offered their assistance and co-operation with the inspection. This inspection finds that the home has made progress in achieving a number of requirements made from previous inspections but a more proactive approach from the manager is needed to initiate further improvements and to take prompt action to address issues, which may otherwise have a detrimental effect on the people living at the home. What the service does well: People were forthcoming in providing positive comments about their lives at Fallings Park Lodge, comments included -‘I’m happy here-I haven’t got any complaints’ ‘staff are very good, they come to you quickly, look after you’, ‘I don’t need much help as I do things for myself but staff are there if you need them, food good, drinks during the day’ ‘carers are good, helpful –you can have a laugh and a joke with them too’. Observations of staff working show that staff treat people with dignity and respect and a good rapport appears to exist between care staff and people living at the home. Staff identify peoples’ likes, dislikes and preferences and comments from people confirm that their care is provided to take these into account. Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although there has been some positive development as to how the home plans care and assesses risk, this is not consistent. Observation of one person’s care records show that a care plan had not been drawn up to provide information and guidance to staff on how to manage an infection and records describe how some staff had not been providing adequate catheter care - with no apparent management intervention to address this. Observation of medication administration charts shows that the home needs to ensure that people receive their medication as prescribed and that staff are competent in administration of medication such as ear drops. People are now provided with a range of activities although further effort needs to be taken to ensure activities are provided so as to enhance the well-being of people with dementia. Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 7 The home needs to be more rigorous with infection control processes and to provide an environment that is well-maintained, where action is taken quickly to address any deficits. Hot water at all outlets accessible to service users should be monitored and action taken to ensure that the temperature is maintained at 43ºC, this is to reduce the risk of scalds to people at the home. 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. Fallings Park Lodge DS0000068603.V348862.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 Fallings Park Lodge DS0000068603.V348862.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3. Quality in this outcome area is adequate. The home has the processes in place to enable the successful admission of a person to Fallings Park Lodge. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection in June 2007, a lack of robust recording meant that the home was unable to demonstrate how people had been assessed and consulted with either before or at the time of their admission to the home. Observation of care files at this inspection shows that the home has completed admission documentation on a retrospective basis and has put in place additional documentation which demonstrates that the home has consulted with people regarding their preferences, choices, likes and dislikes. New admission documentation also provides for assessment of a person’s cultural and religious needs. There have not been any new admissions to the home for sometime, therefore the home’s pre-admission assessment process could not Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 10 be fully assessed and the admissions procedure could not be discussed with people to establish their views on the process. The home has made some improvements to the Statement of Purpose and Service User guide but both documents require further work to ensure that people are provided with up to date and accurate information about the home, for example the Statement of Purpose refers to the home having a complaints procedure but does not state what the actual procedure is. The care files that were seen contained a ‘terms and conditions’ form, which had been signed by the person living at the home-not all of these forms contained information about the fees charged by the home. It was discussed with the manager that it is good practice for the date to be entered when these forms are signed and that people should be provided with a copy of the terms and conditions for their own personal reference. Fallings Park Lodge DS0000068603.V348862.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is poor. The home does not yet have robust processes in place to ensure that the personal and healthcare needs of people living at the home are consistently met, this means that people are placed at risk of not receiving adequate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at the home who were spoken with were forthcoming in their views of how they enjoy living at Fallings Park Lodge, providing comments such as-‘I’m happy here-I haven’t got any complaints’ ‘staff are very good, they come to you quickly, look after you’, ‘I don’t need much help as I do things for myself but staff are there if you need them, food good, drinks during the day’ ‘carers are good, helpful –you can have a laugh and a joke with them too’. Throughout the inspection staff were attentive in meeting people’s needs and a good rapport appeared to exist between people living at the home, visitors and care staff. Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 12 Since the last inspection, the home has changed some of the documentation used to assess, plan and review peoples care needs. Staff were positive about the changes stating that they feel more involved in contributing to the care planning process. Observation of two people’s care records shows a greater emphasis on seeking people’s preferences, likes and dislikes and this information is then incorporated into ‘daily living plans’, providing staff with guidance on such areas as what time people like to get up/go to bed, their sleep pattern, meals and drinks preferences-people spoken with confirmed that staff are following what is documented within this care plan. Individual risk assessments, looking at factors such as how to move people safely and risk of pressure sore formation have recently been reviewed and observation of one person’s care file showed that staff had looked at the risk involved in someone using a mobility scooter, and an appropriate risk management plan had been implemented. Although some positive developments have occurred with how the home plans care and assesses risk, what became apparent when looking at one person’s daily care records were numerous entries by staff describing how basic catheter care had not been provided by other staff earlier in the day-observation of this person’s care records shows that this had occurred on numerous occasions over several months. This individual also had a specific infection but a care plan had not been drawn up to provide information and guidance to staff on how to manage this infection and to reduce the risk of cross-infection. The person’s care records made reference to a cream being applied but did not detail the type of cream. Observation of this person’s Medication Administration Record (MAR) chart detailed prescribed treatment for the infection but had not been signed by staff to confirm the treatment had been given. The way in which staff record care on a daily basis has been changed and staff are now recording less information within daily care records but are recording more detailed information within a ‘communication/handover’ book-senior management were informed that it should be the person’s care records which should contain all ‘key’ information pertaining to that individual. Photographs of people living at the home are now available to assist with correct identification during medication administration. During observation of a selection of MAR charts it was found that the numbers of antibiotics for one person did not tally with that recorded on the MAR chart, medication prescribed for four hourly use was being administered on an ‘as required basis’ with no evidence to show that staff had sought advice from the person’s GP and for one person who requires staff to administer ear drops it could not be established whether the staff were competent for this task. Records to show that the home has been monitoring the temperature of the drugs fridge could not be located at the time of the inspection and although the manager confirmed that the home is monitoring the temperature of the medication room, records have not been maintained to this effect. A thermometer in the medication room showed the temperature to be 26ºC. Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 13 Fallings Park Lodge DS0000068603.V348862.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. Quality in this outcome area is adequate. The home provides people with a range of social activities but further developments are needed to ensure that people with dementia are provided with suitable activities to enhance well-being. The meals at the home are good with choices offered at each meal to ensure that people’s preferences are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation of care records for and discussion with people living at the home shows that improvements have occurred in the availability of activities both within and outside of the home. People spoke of their enjoyment at visiting a local Bingo hall recently, transport had been provided and around 23 people participated, the home has had a summer fete and singing entertainers have visited the home. Individual records on the dementia care unit confirm people’s attendance at events including those described above and in Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 15 participation with daily activities provided by care staff such as board games, dominoes, watching TV and films. Each visit to this unit found people content and cheerful watching television and staff communicating well. From discussions with staff and observation of records it shows that although activities are provided, there is no specific provision of activities based on good practice guidance for people with dementia. The manager and responsible individual were informed during feedback of examples of where to access information to assist with meeting the social needs of people with dementia. People spoken with confirmed that their visitors are able to visit the home at anytime-one visitor spoke of how they are made to feel welcome whenever they visit the home and that staff are quick in communicating any changes with their relatives condition. All people spoken with described the meals provided by the home as good and confirmed that alternatives to the menu are always available. The meal served at lunchtime looked appetising and appeared to be enjoyed by all. Staff showed good interactions with people who needed assistance with feeding and throughout the day people were provided with regular drinks and staff assisted as necessary. Since the last inspection the local environmental health department has visited the home for the purpose of looking at food safety and observation of the report shows that the home was awarded a ‘3 star rating’-indicating a good level of legal compliance in this area. Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 16 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. Quality in this outcome area is adequate. Improvements to the complaints process ensure that people living at the home and/or their representatives are listened to and their concerns acted upon. Staff have not been provided with training to equip them with the knowledge and skills to safeguard adults from the risk of abuse or neglect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure, which is prominently displayed on a wall in the reception area. Since the inspection in June 2007 the home has amended the written procedure and this now provides clear and up to date information to people should they wish to make a complaint. All people living at the home spoke of how they would feel comfortable to inform staff or management if there was something that they didn’t like or to discuss an issue that concerned them. A visitor to the home confirmed her awareness of the procedure but commented that ‘there has been no reason to raise any concerns as everything has been good’. The way complaints are recorded has improved and the record now provides information about the action taken in response to a complaint and any outcomes. Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 17 A discussion with the responsible individual confirmed their awareness of the action to be taken in the event of an allegation of abuse. The home does have a whistleblowing procedure for staff however the manager was informed that the home’s own adult protection policy appears somewhat outdated and was advised to obtain a copy of the recently updated local area adult protection policy. Staff stated that they had not yet received training in adult protection/abuse awareness –the manager confirmed contact with the local adult protection co-ordinator and the intention is for staff to receive adult protection training. Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is poor. The home does not have all systems in place to promote effective infection control and a failure to provide an environment that is safe and well maintained is putting people living at the home at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home offers spacious individual bedrooms, all of which have an en-suite facility and communal lounges provide people with a range of places to relax. Observation of a selection of individual bedrooms found them to be clean and decorated to a good standard-people spoke of their satisfaction with their bedrooms. The manager confirmed that people can have a key to their Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 19 bedrooms if they so wish, although none of the current people living at the home have a key at the moment. Handwashing facilities are provided for staff in people’s bedrooms to encourage staff to maintain good hand hygiene whilst assisting with people’s personal care and training records show that staff have now received training in infection control. During a tour of the home it became apparent that the home needs to be more rigorous in infection control processes as it was established that a care plan had not been created for a person with an infection, meaning that there was no guidance for staff. Laundry in this person’s room was on the floor in a bag, the room did not have a lidded bin and no soap was available for staff to wash their hands in the laundry. The manager was advised to contact the infection control specialist for advice on obtaining dissolvable laundry bags to limit staff contact with infected and soiled linen, as the home does not currently have access to these. Some parts of the home were identified as needing attention, including a shattered glass panel next to the entrance doors on the dementia care unit, a spare set of shelves which were not fixed to the wall on the dementia unit, a toilet without a seat, excessive hot water temperatures and fire safety deficits –all of these issues were brought to the manager’s attention for action to be taken. Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is adequate. The home has improved its recruitment processes and this protects people living at the home from the employment of inappropriate staff. Training opportunities for staff have improved although the management team need to ensure that staff are competent to carry out the duties for which they are employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home continues to accommodate 33 people, 10 of whom are on the dementia unit and staffing levels for the whole home remain at five care staff between 7.30a.m. and 10p.m. and three care staff at night. The manager is not included in the staffing numbers and the deputy manager also has time allocated for administrative duties. People living at the home commented that staff attend to their needs promptly and described staffing levels as sufficient to meet their needs. Staff spoke of how the staffing levels are usually sufficient to meet the needs of the people currently living at the home, but stated the view that the levels will need to be increased when more people are admitted to the home. On several occasions during the inspection only one member of care staff was available on the dementia care unit and one staff member described how the administration of medication often results in only two members of staff being Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 21 available to oversee the ground and first floor of the home-both these issues were fedback to the manager and responsible individual. It was also emphasised that they must provide sufficient staff to ensure residents’ safety until issues pertaining to fire safety have been resolved. Records of staff have attended training have improved. The ‘training matrix’ demonstrates that the majority of staff have been provided with training in the areas of health and safety, infection control, moving and handling, fire safety and first aid. Staff spoke of how training opportunities have improved and confirmed that they have been enabled to access NVQ level 2 in care-the training matrix shows that around twelve care staff have now attained NVQ 2, with other staff in the process of studying for this qualification and four staff have NVQ level 3 in care. No evidence was available to show that staff have received training or been assessed as competent in performing basic catheter care or in the administration of ear drops. The last inspection identified a lack of training for staff in dementia care-some staff have now received some training in this area and information was available which shows that further training is planned via a local college. Observation of a selection of staff files demonstrates that the home has audited staff personnel files and rectified previously identified recruitment deficits- CRB’s were present on those files seen. At the inspection in June 2007 it was established that staff had not been provided with adequate induction training-this is now being provided on a retrospective basis using ‘Skills for Care’ induction standards and most staff have now completed this induction. Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 22 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 37 and 38. Quality in this outcome area is poor. The manager needs to develop a more proactive approach to managing the home, and initiate prompt action to address issues which may otherwise have a detrimental effect on the people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspection in June 2007 identified considerable failings with the leadership and management of Fallings Park Lodge and of particular concern was an apparent lack of attention to legal requirements, resulting in a service which Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 23 was failing to safeguard people living at the home. This inspection finds that the home has made improvements in a number of areas, achieving or partly achieving some regulatory requirements but needing to implement prompt action in achieving other requirements and to provide an environment which is safe. Findings at this inspection show that the manager needs to develop a more proactive approach to managing the home, such as initiating action without delay to address issues which may have a detrimental effect on the people living at the home. An example of this is an apparent lack of management intervention when it appeared that staff were not providing satisfactory catheter care on numerous occasions over several months, the manager confirmed awareness of this issue but could not demonstrate that anything had been done, such as initiating staff training and updates. The manager described a process of senior staff showing more junior staff how to care for a catheter-this does not provide an adequate assessment of competence. Since the last inspection a new deputy manager has been appointed, Susan Swift who has also taken on the role of ‘responsible individual’ for the home. Both the manager, Yvonne Lavender, and Susan Swift were on duty for the duration of the inspection. People living at the home and care staff spoke of how the management team are approachable. The home has started a process of monitoring quality within the home and has recently distributed questionnaires to people living at the home-completed copies were seen on a number of care records and the responsible individual spoke of the intention to collate the responses to form an action plan. A ‘residents’ meeting’ was held in July and minutes show that this meeting focussed on the provision of activities. Records show that six staff have attended individual supervision sessions and the management team spoke of the plan for supervisory responsibilities to be cascaded through the care team. A member of staff who was spoken with commented favourably regarding the supervisory process now in use at the home finding their first ‘one to one’ supervision session beneficial. Supervision sessions so far have been provided by Ms Swift, who has no formal qualifications in management or staff supervision. Observation of individual financial records shows that the home has introduced a process of requiring two signatures for all transactions, thus providing a more robust approach to the management of people’s personal monies. Improvements have occurred with how the home maintains documentation such as individual care records, staff personnel files and records pertaining to health and safety, such as in the recording and reporting of accidents and incidents. Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 24 Records show that the home is now monitoring hot water temperatures and fire safety checks have been undertaken. However records of water temperatures do not provide any confirmation of action taken when temperatures fall outside of the recommended range, for example in July 2007 water from a wash hand basin in the lounge on the dementia care unit was recorded as 50°C but there is nothing recorded to show what was done to ensure people and staff were made aware of this excessive temperature. On the day of this inspection hot water temperatures measured at a bath and sink on the dementia care unit found that they were excessive at 48°C, which demonstrates that the home has not yet implemented a robust process of monitoring hot water temperatures to reduce the risk of scalds. The fire officer visited the home the day after the last inspection as serious concerns regarding fire safety had been identified during the inspection. A subsequent visit by the fire officer in July 2007 showed that the home had addressed most deficits apart from the fitting of an override device, the purpose of which is to ensure that certain locks can be opened quickly in an emergency situation. At the time of this inspection it was found that the device was not in working order for the dementia care unit, the manager and responsible individual were informed that they must ensure that staff are fully aware of the procedure to follow in the event of an emergency and that adequate staff must be on duty to ensure the safety of people living at the home. A visit by the fire officer the day after this inspection provides confirmation that the home has now addressed fire safety deficits. The bedroom for one person risk assessed by the home as needing bed rails was observed and it was seen that the appropriate type of bed rails were now in use and secured appropriately to this person’s bed. Fallings Park Lodge DS0000068603.V348862.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 CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 1 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 1 X 3 X 3 2 2 1 Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 4 5 Requirement The statement of purpose and service user guide should be reviewed and amended. This will ensure that people admitted to the home are provided with accurate and up to date information on the services offered by the home. (20/08/07-Not fully achieved. Previous timescale of 01/08/07) Timescale for action 01/11/07 2. OP3 14 People must be assessed and consulted with prior to admission to the home. This is to ensure that the home is certain it can meet the person’s care needs. (20/08/07-Unable to fully assess compliance as no new admissions to the home. Previous timescale of 20/08/07) 01/11/07 3. OP7 15 People living at the home must have their care needs assessed and planned in the form of a care plan. This will provide information to staff on how the person’s care needs are to be met. (20/08/07-Compliance not achieved. Previous timescale of 20/07/07) 01/11/07 4. OP9 13(2) Medication must be stored in accordance with manufacturers’ DS0000068603.V348862.R01.S.doc 01/11/07 Fallings Park Lodge Version 5.2 Page 27 instructions This is to ensure that medication is stored correctly to prevent people being placed at risk of harm and from receiving ineffective medication (20/08/07 Unable to assess compliance as records not available. Previous timescale 20/07/07) 5 OP9 13(2) 6. OP12 16(2)(m) Medication must be administered according to the prescriber’s instruction and staff must sign to confirm administration. This is to ensure that people receive all of their prescribed medication. People living at the home must be provided with a range of activities that meet individual needs and capabilities. This is to promote well-being and ensure that the social needs of people living at the home are met. (20/08/07 Partially achieved. Previous timescale of 01/03/07 and 20/07/07) 01/11/07 01/11/07 7. OP18 13(6) Arrangements must be made to 01/11/07 ensure that all staff have a clear understanding of adult protection and whistleblowing procedures. This is to ensure that people living at the home are protected from harm or abuse. (20/08/07 Compliance not yet achieved within timescale of 20/08/07). 8 OP26 13(3) 9. OP30 18(1)(c ) (i) Infection control procedures must be in place and followed by staff. This to reduce the risk of infection and to ensure people are protected by the home’s infection control systems Staff must be provided with training appropriate to the work they are required to perform. This will ensure that staff have the skills and knowledge to meet the needs of the people living at the home. (20/08/07-Compliance not fully DS0000068603.V348862.R01.S.doc 01/11/07 01/11/07 Fallings Park Lodge Version 5.2 Page 28 achieved. Previous timescale of 01/08/07) 10. OP33 24 A system for evaluating the quality of the services provided at this home must be implemented, which actively seeks the views of people using the service, their representatives and other stakeholders. The results should then be used to improve the home’s performance based on the feedback from others. (20/08/07-Assessed as work in progress. Previous timescale of 01/08/07 01/11/07 11 OP38 13 (4)(a) (c) Hot water at all outlets accessible to service users should be monitored and action taken to ensure that the temperature is maintained at 43ºC. This is to reduce the risk of scalds to people at the home. (Previous recommendation) 01/10/07 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 OP2 Good Practice Recommendations The home’s ‘terms and conditions’ should include accurate information on the fees charged by the home, detail who is responsible for ensuring payment of these fees and be drawn up in consultation with the service user and his/her advocate. This will ensure that people are fully informed of the total fees payable and the arrangements in place for the payment of fees. (20/08/07 Not fully achieved) 2. OP9 The temperature of the rooms used to store medication should be monitored and recorded. This is to ensure that DS0000068603.V348862.R01.S.doc Version 5.2 Page 29 Fallings Park Lodge medication is stored at the correct temperature. (20/08/07 Not achieved) 3 OP18 4. OP19 The home needs to obtain a copy of the new local area adult protection policy. This is to ensure that the manager and staff are kept informed of the processes to follow should any incident or allegation of abuse occur. All parts of the home, including bathrooms and toilets must be kept and in a good state of repair. This is to ensure that people are provided with a clean, homely and safe place to live and where their dignity is not compromised. . (20/08/07 not achieved) 5. OP30 To ensure staff are competent in the use of the use of the newly acquired pressure relieving mattresses training should be provided. (Recommendation made on 29/03/07. 20/06/07-no evidence to confirm that staff have received training 20/08/07-Not assessed at this inspection)). 6. OP30 Care staff should receive training in dealing with challenging Behaviour (Recommendation made on 16/01/07 Assessed as not achieved on 20/06/07. 20/08/07-Not assessed) Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection 1st Floor Chapter House South Abbey Lawn Abbey Foregate Shrewsbury SY2 5DE 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 © 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 Fallings Park Lodge DS0000068603.V348862.R01.S.doc Version 5.2 Page 31 - 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. 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