Inspection on 06/10/05 for Fieldhead Park Care Home

This inspection was carried out on 6th October 2005.

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

Fieldhead Park Care Home 09/02/09

Fieldhead Park Care Home 11/03/08

Fieldhead Park Care Home 14/03/07

Fieldhead Park Care Home 29/06/06

Fieldhead Park Care Home 02/02/06

Fieldhead Park Care Home 08/12/04

Fieldhead Park Care Home 25/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Fieldhead Park Care Home 140 Kitson Hill Road Mirfield West Yorkshire WF14 9QZ Lead Inspector John Gregory Unannounced Inspection 07:45 6 October 2005 th 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 Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 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. Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fieldhead Park Care Home Address 140 Kitson Hill Road Mirfield West Yorkshire WF14 9QZ 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) 01924 496517 01924 496317 Roche Healthcare Limited Mrs Maria Hawksworth Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (54) of places Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named person aged under 65 years of age To accommodate a maximum of two services users aged between 55 and 65 years in the ten immediate care bed unit. 8th December 2004 Date of last inspection Brief Description of the Service: Fieldhead Park is a care home providing accommodation and personal care for 54 persons who are experiencing issues relating to the ageing process. Ten of the places are reserved for persons requiring intermediate care. The accommodation is an extended and adapted former Victorian detached property in its own grounds. It is owned by a private limited company that own other homes in the West Yorkshire area. All but two of the bedrooms are for single occupancy; all the rooms have ensuite facilities. The facilities are based over two floors that are joined by two passenger lifts. The home has a number of lounges and dining facilities. The home is sited some distance from the town of Mirfield, within a short distance of some local facilities. Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and undertaken by two inspectors over the course of one day in October 2005. Only those standards were inspected that the CSCI determine are central to the caring process. A sample of policies, procedures and records were examined that were relevant to the standards inspected. Ten service users’ files were examined, 3 of which were subject to detailed analysis. Ten staffing files were examined. Interviews were undertaken in private with eight service users and 9 staff. A brief tour of the accommodation was undertaken. The area manager, the home’s manager and joint acting manager assisted the inspectors. The inspectors would like to thank the service users, staff and managers of Fieldhead Park for their time, cooperation and hospitality during this inspection. What the service does well: What has improved since the last inspection? What they could do better: The care planning system needs to become more consistent and detailed in its direction. The service provider must make the home a safer place to live, through the Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 6 development of both the recruitment practices and developments in the area of the prevention of abuse to adults. The formal supervision of staff should become part of the home’s management practices. The safety of staff and service users needs to be improved by attention to all health and safety issues and development of fire safety practice. 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. Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 7 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 Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. The service users are admitted to the home on the basis of good assessments that ensure that the service users’ social and health needs can be met. The service provider offers a good service to persons requiring intermediate care. EVIDENCE: The files examined all contained evidence of a pre-admission assessment being undertaken by managers of the home or through the care management arrangements. Service users receive written confirmation of the ability of the home to meet their assessed needs. The assessment informs the development of the care plans. Service users receiving intermediate care are assessed through the local hospital and specialist nursing services. Intermediate care is delivered in a specialist area of the home by staff who are designated to the unit and who have specialist rehabilitative experience. Some past service users of this service have been admitted as long term service users of the main home after multi-disciplinary assessment. Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 9 Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 The care planning system needs attention in terms of consistency, frequency and detail in order to ensure that service users’ needs are met. Service users receive good medical care and the medication processes basically protect service users, although some attention is necessary to the detail of the process. Service users have their dignity and privacy respected. EVIDENCE: All the service users had a care plan although they varied in the consistency to which they covered areas relevant to the service user’s care; addressing service users’ social care needs did not feature in the care plans. Generally the plans need more attention to detail. Risk assessments were completed but the areas covered by the assessments lacked consistency. In order to keep the plans relevant to the service users’ care, the plans need to be reviewed monthly by care staff. There was evidence of service users’ families being consulted in the care planning process, however service users were less aware of the use of care plans. Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 11 There was good evidence on file, confirmed by service users, that they receive good medical services from the primary health care team and other health care professionals. The medication procedure needs to be developed to cover all the areas mentioned in the Royal Pharmaceutical Society Guidance in order to fully protect service users. The home’s manager was in the process of re-drafting the procedure at the time of the inspection. The medication of seven service users was audited and found in the main to be accurate. The carried forward figure of boxed medication needs to be noted on the MAR sheet in order to ensure that the practice fully protects service users. Service users expressed a high level of satisfaction with the services on offer; interactions with staff were seen to be positive. The service users’ privacy was demonstrably protected by the care being based on single rooms, some service users having their own phones, the two double rooms having screens, service users using their own clothes and having a good degree of personalisation of their rooms. Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Service users have good access to a range of activities that satisfies their needs and have unlimited contact with family and friends. Service users have access to many choices in their lives. A good wholesome and appealing diet is provided. EVIDENCE: Service users were able to confirm that a good level of activities were available in the home through the designated activities coordinator. The craft based activities and trips out to local places of interest were highly rated by service users. All service users commented positively on the way in which their family and friends could visit at any time, share meals and involve themselves in open days and special events. Similarly, service users described choices of whether they involved themselves in activities, where they ate their meals, when they went to bed and when they arose. A good level of satisfaction was received from service users about their choice of meals and the quality and quantity of the food. Choices were confirmed through the three weekly menu cycle and the record of food served. Service Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 13 users have the choice of whether to eat the meals in the communal dining areas or in their own rooms. Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 More work is necessary through training to ensure that complaints are taken seriously, acted upon and reflect the confidence expressed by the service users in the procedure. Development is necessary of all the processes to ensure that service users are protected from abuse. EVIDENCE: The complaints procedure was displayed in the entrance to the home and contained in the Service User Guide within the home. The records indicated that there had been no complaints since the last inspection. Service users were confident that any concerns that they may have would be dealt with but, like staff, were less than clear on how the procedure operates. The procedure for the prevention of abuse to adults has good features but needs to contain links to the local joint agency procedure. The whistle blowing procedure was basic and did not describe the external agents that staff should contact in the case of concern. On interview, staff lacked confidence in describing the procedures and, although staff training has begun on the issues, the current plans are insufficient to cover all staff. Following a recent incident in the home, the action plan offered by the service provider had not been implemented with the degree of urgency implied in the document. This plan included a full package of training on issues of abuse and communication. Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 15 The service provider must address these issues to ensure that service users are fully protected. The service provider must undertake full risk assessments on those service users who have sides fitted to their beds. Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The service users live in a safe well-maintained environment that is basically clean and hygienic to which only minor attention is needed. EVIDENCE: A brief tour of the accommodation was undertaken which have been developed, in recent times. The accommodation was in the main well decorated and maintained and furnished in a domestic fashion. However, the carpet in the small lounge was badly stained and needs replacement. The carpet in the large lounge was stained and needs attention to ensure that it is properly cleaned. The laundry was well equipped with commercial equipment, had impervious walls and flooring with hand washing facilities available for staff. Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 The home is staffed to provide a basic level of care for service users. The staff recruitment process has improved and now mainly protects service users although minor attention is needed to its processes. The current level of staff training is low and needs to be developed in order to ensure that staff are fully trained to do their jobs. EVIDENCE: The home’s staffing is based on six staff and one nurse being on duty during day time hours with one nurse and four staff being on waking night duty for longer term service users. One nurse and one care assistant separately staff the intermediate care unit during waking hours. This level is sufficient for the basic care needs of service users but would not support the necessary time for training, supervision and communication noted in other areas in the report. Good levels of ancillary and catering staff support the staffing level. The recruitment process is basically sound but attention must be paid to obtaining two references for all staff and to an assessment of the health needs of the person. Staff have only received training in the past six months limited to basic health and safety training with the beginnings of some prevention of abuse training. This should be expanded to include areas directly relevant to the care of service users. Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 &38 The service provider is taking positive steps to address some of the issues in the home through restructuring the management of the home. This will include the development of a quality assurance system which currently does not exist. Service users’ financial interests are protected. The arrangements for fire safety in the home do not fully protect service users and action is necessary on a health and safety matter to protect both staff and service users. EVIDENCE: The home’s current registered manager is to move for some of her time to address quality issues with the company. The balance of managerial time is to be taken on by the acting manager who has applied to the CSCI for registration. One of the current manager’s responsibilities will be to develop a Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 19 quality assurance system which currently does not exist within the home. The absence of a quality assurance system was the subject of a statutory requirement at the last inspection. In the light of the structural progress made by the service provider, a new timescale is given. The financial records of four service users for which the company has agency functions were examined and found to be in order. The service provider has a comprehensive set of policies, procedure and records for health and safety including a work place risk assessment. These records are restricted to the building but do not include risk assessments on the moving and handling of service users. This shortfall breaches the statutory requirement made at the last inspection. A new short timescale is given which, if not adhered to, may result in the CSCI taking enforcement action. Records of fire risk assessments, fire and emergency lighting were seen however there was no evidence of simulated fire drills having taken place for which a requirement already exists. The CSCI will consider enforcement action if this matter is not addressed within a short timescale. COSHH records exist in the home as do records about food and water temperature. PAT and mains services tests were available. Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 20 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 X 3 X X 3 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 2 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 1 Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 21 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 OP18 Regulation 13(6) Requirement Timescale for action 01/12/05 2 OP29 19 Schedule 2 3 OP33 24 (1) 4 OP38 23(4) The service provider must make arrangements, by training of staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse The service provider must obtain 01/12/05 the following information in respect of persons working in the care home: Two written References A statement by the person as to their physical and mental health The service provider must 01/04/06 establish and maintain a system for reviewing at appropriate intervals and improving the quality of care in the care home. Previous timescale of 31.03/05 not met. The service provider must 01/11/05 ensure by means of fire drills and practices at suitable intervals, that the persons working at the care home, and so far as practical, service users are aware of the procedure to be followed in the case of fire DS0000001083.V250859.R01.S.doc Version 5.0 Fieldhead Park Care Home Page 22 5 OP38 13 (5) including the procedure for saving life. Previous time scale of 31/01/05 not met The registered person must 01/11/05 make suitable arrangements to provide a safe system for moving and handling service users. Previous timescale of 15/01/05 not met 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 3 4 5 6 7 8 Refer to Standard OP7 OP7 OP7 OP9 OP9 OP16 OP19 OP30 Good Practice Recommendations Care plans and risk assessments of service users should become full and more consistent with a greater level of detail. All service users care plans should contain details of social need. All service users care plans should be reviewed monthly by care staff The medication procedure should be developed in line with the Guidance offered by the Royal Pharmaceutical Society The carried forward figure of Boxed medication should be recorded on the MAR sheet. All staff should receive training in the management of complaints. Carpets in the lounges should be replaced or effectively cleaned. Staff training should be developed to cover all areas necessary for the care of service users. Fieldhead Park Care Home DS0000001083.V250859.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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