Inspection on 04/12/07 for Fallings Park Lodge

This inspection was carried out on 4th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 20/08/07

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 4th December 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fallings Park Lodge DS0000068603.V355900.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.V355900.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 *Post vacant* 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.V355900.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 August 2007 Date of last inspection Brief Description of the Service: Fallings Park Lodge is a 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 people with dementia. The home has extensive gardens and grounds, with raised flowerbeds at the rear and there is car parking at the front of the building. At this inspection weekly fees are confirmed as £349-£400 per week. The reader is advised to contact the home to obtain up date information on the fees charged. People can obtain information about this service from the home’s Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk. Fallings Park Lodge DS0000068603.V355900.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. A range of evidence was used to make judgements about this service which included discussions with people living at the home, speaking with staff and observing them in their work, looking at care records and other documentation. This is the third ‘key’ inspection undertaken by CSCI in the past six months, and like previous inspections, the purpose of this inspection was to look at what improvements had taken place since the last inspection and to assess all ‘key’ standards -that is those areas of service delivery that are considered essential to the running of a care home. Since the last ‘key inspection’ in August 2007 there has been a change in management arrangements-the person reported to be the responsible individual at that time is now working in the capacity of ‘acting manager’, pending the appointment of a new manager in mid December. The acting manager appears to have tried to provide some stability to the home, but a lack of experience and no apparent guidance from a senior level has resulted in further shortfalls in how this home is operating. Where the home had previously made some improvements - such as with staff recruitment and the management of complaints – this inspection finds these improvements have not been sustained and the home is yet again failing to adequately safeguard people from the risk of harm. A CSCI pharmacist inspector undertook an inspection in October 2007, which identified failings with the management of medicines within the home. The report for that inspection is available from CSCI as a separate inspection report. What the service does well: People provide positive comments about the care they receive, comments received during the inspection include:- ‘carers can’t do enough for you, always helpful, food very good, what more could I want’, ‘carers are golden, can’t fault them, helpful, kind, food good’. Throughout the inspection staff were attentive, offering drinks, snacks and helping people. Observations of staff working showed that the staff on duty at the time of inspection treated people with dignity and respect. Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home has failed to respond to complaints including two of an abusive nature and recruitment processes are again poor, which means that the home is failing to safeguard people living at the home. Staffing levels are insufficient for the number and dependency of people living at the home. Care plans are not in place to show how people want their needs to be met or the action needed by staff to meet the person’s needs safely and effectively. The current medicines storage arrangements are not effective in ensuring medicines are stored at the correct temperature. The environment is not satisfactorily maintained and when issues are identified, such as excessive hot water temperatures, they are not attended to promptly by the provider. As identified at an earlier inspection the management team at the home and the provider do not seem aware of how to make improvements to the service or how to prioritise areas for improvement, without intervention and guidance from other agencies. What gives us particular concern at this inspection is that where improvements have previously occurred, such as with staff recruitment, the home has not sustained these improvements, which does not give us the confidence that this home is capable of complying with legislation and providing a service which is ‘fit for purpose’. Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 7 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.V355900.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.V355900.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 and 3. Standard 6 is not applicable to this service. Quality in this outcome area is adequate. The home has a Statement of Purpose and Service User guide, which provides people with basic information about the home. There are 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: The home’s Statement of Purpose and Service User Guide have now been revised and, combined with the inspection report on display in the hall, provide basic information about the service. Terms and conditions of residence have been amended to show the fees payable. Since the last key inspection in August 2007 one person has been admitted to the home and the care file for this person was looked at. This showed that the acting manager had conducted an assessment of this person’s needs and Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 10 obtained information from other care professionals involved in this person’s care before the person was admitted to Fallings Park Lodge. The assessment completed by the acting manager focussed on a range of areas including the person’s personal preferences, any religious or communication needs, safety and risk factors, mobility needs and whether equipment is needed to safely move the person. Although the assessment was satisfactory what it didn’t trigger was the development of individualised care plans and risk assessments to describe how the care and any risks to the individual were to be safely managed. The assessment did not show how the person’s significant others had been involved in the admission process. Fallings Park Lodge DS0000068603.V355900.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 is not developing care plans with people to show how people want their needs met and the interventions needed by staff to meet their needs this means 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: As at other inspections people spoke positively about how they are looked after by the care staff, comments included ‘carers can’t do enough for you, always helpful, food very good, what more could I want’, ‘carers are golden, can’t fault them, helpful, kind, food good’, ‘ can’t fault the carers, food good, choice, better than it used to be’, ‘carers are good, 1 or 2 aren’t so good but I tell them that’. People who weren’t able to give their views, appeared content, clean and comfortable and during the day staff were attentive, offering drinks, snacks and helping people. Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 12 Observation of the care files for two people show that staff document people’s likes, dislikes and preferences and complete risk assessments in respect of the person’s risk of falls, pressure sore formation, moving and handling and nutritional risk. This inspection, like previous inspections shows that the home is failing to develop care plans with people which set out in detail how the person wants their needs met and the action needed by staff to meet the person’s needs. For example, an assessment completed by the social worker for the person recently admitted to the home describes how the person has problems with their memory and is prone to ‘wandering’ - there was nothing within the care file to guide staff as to how they should provide care to manage these problems safely and effectively. A care plan had not been generated for another person who has expressed concern about not being heard by staff if they have to call for assistance - a discussion with this individual found they are still concerned about this issue, and no apparent action has been taken by the home. The acting manager acknowledged a lack of awareness of care planning and risk assessment processes. Our pharmacist inspector visited the home in October 2007. This resulted in the home needing to take immediate action with regard to the management of medication in a number of areas. The pharmacist inspector found that medication was not being stored properly, some people were not receiving their medication as prescribed, and appropriate risk assessments and care plans were not in place to ensure medication was administered safely and correctly. The pharmacist inspector made six requirements. The acting manager has started to check medicine administration record sheets on a regular basis, which shows that some staff are still not completing records accurately. At the moment this is not resulting in any follow up action with the staff members concerned. Observation of the records for the temperature of medication room shows that this temperature remains too high, the room was notably warm at the time of inspection and a portable air conditioning unit was in place but was blowing out hot air. It was confirmed that a specific cabinet for the storage of ‘Controlled Drugs’ is on order. Fallings Park Lodge DS0000068603.V355900.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14 and 15. Quality in this outcome area is adequate. People confirm that the home is providing them with opportunities to enhance their quality of life or well-being. Most people are satisfied with the meals provided by the home, although further attention with the ‘tea-time’ menu should ensure that people’s preferences are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People spoke of how they have enjoyed trips out of the home recently, including a meal out and a visit to see the ‘Christmas lights’. A return visit to the home a week after this inspection found some people going out to another local event. One person spoke of how the home has started to do more activities and gave examples of visits outside of the home. However observation of the written records did not correspond with this and from reading the records it appeared Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 14 very little had taken place, similar findings were also found in other people’s records, which shows that staff need to be more careful in their record keeping. Feedback from mental health professionals indicates improvements with the provision of activities for people with dementia. The home has a four week menu plan for the main lunch time meal. A menu plan is being devised for the tea time meal, which is described as currently including toast, sandwiches, burgers and soup. It was clear from comments made within a residents’ meeting and in the complaints log that the standard of the food available at tea time needs attention. Breakfast was described as being cereal, porridge, toast or “cooked” if people requested it. The meal served on the day of inspection appeared appetising and it was evident that people could choose what and how much they wanted. The home could improve its service for people with dementia by exploring different options for food provision for people who are reluctant to sit down at a table for a meal. Fallings Park Lodge DS0000068603.V355900.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. The home has a complaints procedure and staff have attended training relating to the protection of vulnerable adults. However, complaints and allegations have not been responded to appropriately and there is no evidence that concerns have been acted upon or that people have been protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure, which is described in the statement of purpose and referred to in the service user guide. This states that complaints will be acknowledged and investigated and that the complainant will then receive a response. At the inspection in August 2007 complaints were well recorded. At this inspection, the complaints log contained a brief description of four complaints from service users and one from a member of staff. Two complaints related to food; one was a complaint from service users about another service user and two were serious concerns about staff conduct. One of these was made by someone who stated that they had been left in urine for Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 16 four hours at night with no response to their call bell, and the other was about the attitude of the night staff when called for assistance, which had clearly caused the complainant distress. There was no account as to how any of these complaints had been investigated or addressed, and no record of a response to the complainants. It has been a requirement previously that staff received training to increase their awareness of adult abuse and their responsibilities within the home’s and multi-agency procedures. The home’s action plan stated that training had taken place by October 2007 and the home’s training matrix now shows that some two-thirds of the staff have now attended. Staff have been provided with a “whistleblowing” policy and required to sign it off, and this was seen on staff files. Despite the training, the two incidents - which lead to the complaints described above - which were possibly abusive were not dealt with appropriately. Fallings Park Lodge DS0000068603.V355900.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is poor. Lack of maintenance is making the home unsafe. Residents are at times put at risk or subject to discomfort. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Communal areas are pleasant and comfortable and those individual bedrooms seen at this inspection were clean and pleasant, particularly where residents’ own possessions have made the rooms homely and individual. However, the home is not being well maintained and issues identified in the safety audits, prepared by the management team, are not being attended to promptly by the provider. This is putting residents at risk e.g. window restrictor not mended, excessively hot water, and/or in some discomfort e.g. bedroom not warm enough, bath water not warm enough, broken toilet seats. The home has two Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 18 hoists to assist residents to move about, but although it was stated that these have had the required maintenance, there is no documentation to support this. It was established that one of the lounges does not have a call buzzer, this had initially been raised as a complaint and the home has not taken any action to address it or provide an alternative system until a call buzzer is fitted. At the time of inspection the home appeared clean and staff were seen using protective clothing appropriately. Staff confirm that dissolvable bags are now used to reduce contact with infected and soiled linen. Fallings Park Lodge DS0000068603.V355900.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 Quality in this outcome area is poor. Staff are now receiving training which should equip them to meet residents’ needs. However, residents are not being protected from potential harm by the home’s recruitment procedures and staffing levels are inadequate for the numbers and needs of the people accommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last key inspection of Fallings Park Lodge, it was reported that there were five care staff on duty during the waking day with three on duty at night. In addition the home then had a registered manager on duty, with additional support from the home’s deputy manager with administration and management tasks. At the time of that inspection, some concerns were raised by staff about their availability at key times e.g. medication rounds, and when a carer left the dementia unit, leaving it staffed by one carer. This was discussed with the managers. At this inspection, the home’s rota (w/c 3.12.07) showed that carer numbers varied between five and four on duty, with the Acting Manager and a Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 20 “supporting manager”. The “supporting manager” is destined to work at another home but is helping out at Fallings Park Lodge until a new manager starts on 17.12.07. In addition to the carers, “trainees” were also rostered on shifts, usually two on day shifts and one on nights. However the rota showed that sometimes on night shifts the “trainee” was the third person on duty (Thursday 6.12.07; Friday 7.12.07; Saturday 8.12.07). It was unclear how staff on duty, also rostered for “training”, covered their shift effectively e.g. on Friday 7 December 2007 although there were five care staff and a trainee on duty, it was noted on the rota that two of the carers and the trainee were “training” – attending Moving and Handling training between 10.30a.m. and 12.00noon. Concerns were again expressed by staff that at times the dementia unit is inadequately staffed. Some residents accommodated within that unit require two carers to assist with personal care and/or bathing, which leaves the remaining residents unsupervised. There are other occasions when one member of staff has to be away from the floor leaving the other single handed. It was established that the “trainees” are in fact employees of the home, and discussions with one trainee confirmed that they are working as care staff without direct supervision. Inspection of the personnel files found that a Criminal Records Bureau disclosure (CRB) had been obtained for only one of the five “trainees”. Preliminary checks that can be conducted against a national list of people considered unsuitable to work in care (POVA 1st checks) had not been obtained. Not all files contained two references and for one person there was no criminal records check and no references. It was also established that the provider had not obtained a CRB for the person brought into the home to support the acting manager. Staff spoke positively about the training they are undertaking, and staff and “trainees” have been provided with a skills for care induction workbook. One “trainee” spoke of the support of her mentor with this and her expectation that she would undertaken training and accreditation to gain a National Vocational Qualification at Level 2 (NVQ2) early in 2008. Training has been provided in a range of areas and more is planned. The home’s training matrix suggests that nobody has as yet had their “skills for care” induction signed off, but most staff have now attended Food Hygiene training, Use of Fire Fighting Equipment, Health and Safety, Moving and Handling, Protection of Vulnerable Adults, Dementia and Infection control training. Four staff have undertaken accredited medication administration training, including the acting manager. Seventeen of the staff have gained accreditation at NVQ2 and a further two people are undertaking this award. Further training courses in moving and handling, First Aid, Food Hygiene and Infection Control are taking place in December. Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 21 Residents generally spoke well of the staff, but instances when complaints have been raised about staff actions and attitude appear not to have been addressed. It was stated that issues identified through safety audits e.g. denture cleaning tablets being left out, beds not being made promptly, were addressed through supervision and staff meetings. Fallings Park Lodge DS0000068603.V355900.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, 33, 35 and 38 Quality in this outcome area is poor. Management arrangements are failing to provide a safe environment for service users. The health, safety and welfare of service users and staff are not being adequately promoted or protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home currently has an acting manager who is being supported by someone who is to take up a management post elsewhere pending appointment of another manager in mid-December. Management arrangements have been unsettled with various plans not coming to fruition, Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 23 meaning that the acting manager – who lacks experience and qualifications – has been left in charge. It is evident that issues are not being managed well. Maintenance tasks which have been referred “up the ladder” to the company director for action have not been completed, so even when deficits are identified by the management team nothing has been done. Maintenance work which affects the well being of residents has not been attended to, for example: Inadequate hot water temperatures since September 2007 Draughty window which is keeping resident awake at night Room not adequately heated Lights not working on 1st floor Trip hazards Excess hot water temperatures in some areas Of particular concern was that a logged report dated 21.11.07 of a safety chain on a second floor window on the dementia unit being broken had not been attended to. We required that the home addressed this immediately as it posed a significant risk to the occupant of that room. One set of bed rails in use had not been fitted in accordance with relevant guidance on the safe use of bed rails. As reported earlier, complaints and potential allegations of abuse have not been dealt with appropriately. Staff have been recruited to work with vulnerable residents without the required checks on their criminal backgrounds and employment history. Although the home was found to be compliant with fire safety in August 2007, it was found at this inspection that checks had not been conducted at the required frequency. Testing of the fire alarm had been done regularly through July – September but then was only tested once in October. Testing of the emergency lighting also was not documented since 5 September 2007. Although it was suggested that the tests had been carried out and diary entries not transferred to the fire log, there was no evidence in the diary of tests. The most recent fire drill was August 2007 which suggests that new “trainees” had not experienced a drill, although one “trainee” confirmed that she had been told what to do. The two hoists used by staff to assist residents to move were due for safety checks in September 2007. We were told that the hoists had been serviced Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 24 and checked but there was no paperwork to support this. Residents’ wheelchairs were being checked on the day of this inspection. Some safety audits had been conducted, which give rise to the list of jobs which need doing. An analysis of falls had also been done, which did not identify any particular cause or patterns. Records of incidents and accidents appeared good, and a new form, which made it clear what should be communicated to whom has been devised. A systematic approach to quality assurance has not yet been established. There was a residents’ meeting in July 2007 and a questionnaire from a relative received in September 2007 (which was critical of the food provision). As reported under the staffing section above, training has now been provided in essential areas such as infection control, moving and handling, health and safety and food hygiene to support safe working practices within the home. Supervision of staff has started, but a realistic working approach to this requires delegation to senior care staff, who have not yet received training. Systems for managing any residents’ money have been inspected on previous occasions and found to be robust. Consequently they were not inspected again on this occasion. Fallings Park Lodge DS0000068603.V355900.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 3 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 1 Fallings Park Lodge DS0000068603.V355900.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 OP7 Regulation 15 Requirement 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. (4/12/07-Compliance not achieved. Previous timescale of 20/07/07 and 01/11/07) Timescale for action 05/12/07 2 OP9 13(2) Medication must be stored within 10/12/07 the temperature range recommended by the manufacturer to ensure that medication does not lose potency or become contaminated. (4/12/07-Compliance not achieved. Previous timescale of 20/07/07) 3 OP9 13(2) Accurate, complete and up to date records must be kept of all medication received, administered, taken out of the home when residents are on leave and disposed of to ensure that medication is accounted for, is available and is given as prescribed. (4/12/07 not assessed at this inspection, timescale of 12/10/07) 10/12/07 Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 27 4 OP9 13(2) Appropriate information relating to medication must be kept, for example, in risk assessments and care plans to ensure that staff know how to use and monitor all medication including as directed and self administered medication so that all medication is administered safely, correctly and as intended by the prescriber, to meet individual health needs. (4/12/07 not assessed at this inspection) 10/12/07 5 OP16 22 (3) 22 (4) The registered person must 05/12/07 ensure that any complaint made under the complaints procedure is fully investigated and provide a response to the complainant of the outcome of the investigation and the action(if any) to be taken. This will reassure people that their concerns are dealt with effectively so as to reach a satisfactory outcome. If allegations are made then the registered person must comply with multi-agency adult protection procedures (Previous non-compliance at inspections on 29/03/07 and 20/06/07) 6 OP18 13(6) 05/12/07 Arrangements must be made to ensure that all staff have a clear understanding of adult protection and whistleblowing procedures and are competent in responding to allegations. This is to ensure that people living at the home are protected from harm or abuse. (4/12/07-compliance not achieved, previous timescales of 20/08/07, 1/11/07) 7 OP9 13(2) A Controlled Drugs cabinet must be installed correctly in order to comply with new legislation and ensure that Controlled Drugs are stored safely DS0000068603.V355900.R01.S.doc 31/12/07 Fallings Park Lodge Version 5.2 Page 28 (4/12/07-assessed as in progress at this inspection.) 8 OP27 18 (1)(a) Staffing levels in all areas of the home and for all shifts must be reviewed to take account of peoples’ needs, dependency, layout of the home. This is to ensure people’s needs are met safely and promptly. 10/12/07 (4/12/07-compliance not achieved. Previous timescales of 01/03/07, 15/07/07 and immediate requirement for action issued on 20/08/07) 9 OP29 19 Schedule 4 Staff recruited by the home must 05/12/07 have all required preemployment checks undertaken. This is to protect people from the employment of inappropriate staff. (4/12/07-non-compliance. Previous non-compliance at inspection on 20/06/07) 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. (Assessed as work in progress on 20/08/07, little evidence of further action on 4/12/07. Previous timescale of 01/08/07) 31/12/07 11 OP38 13 (4) (c) Bed rails must be assessed, fitted and maintained by a competent person in accordance with MHRA/HSE guidance. This is to protect the person from the risk of harm and promote their safety (4/12/07-non-compliance. Previous non-compliance at inspection on 29/03/07 and 20/06/07). 05/12/07 Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 29 12 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. (4/12/07-non-compliance. Previous timescale of 01/10/07) 05/12/07 13 OP38 13(4)(a) (c) The Registered person must 05/12/07 ensure that all parts of the home to which service users have access are as far as reasonably practicable free from hazards to their safety. This is to ensure that any unnecessary risks to the health or safety of service users are identified and so far as possible eliminated 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 OP19 Good Practice Recommendations 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. . The prescriptions are checked for accuracy by the home prior to them being dispensed by the pharmacy so that the home is fully aware of any issues arising and as a consequence to safeguard the residents against errors in the ordering process. (4/12/07-not assessed at this inspection) 2 OP9 Fallings Park Lodge DS0000068603.V355900.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office Commission for Social Care Inspection 77 Paradise Circus Queensway Birmingham B1 2TD 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.V355900.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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