Inspection on 12/11/07 for Fulwood Park (Methodist Homes For The Aged)

This inspection was carried out on 12th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fulwood Park (Methodist Homes... 09/02/07

Fulwood Park (Methodist Homes... 04/02/06

Fulwood Park (Methodist Homes... 03/12/05

Fulwood Park (Methodist Homes... 23/03/05

Fulwood Park (Methodist Homes... 06/07/04

Fulwood Park (Methodist Homes... 20/02/04

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

CARE HOMES FOR OLDER PEOPLE Fulwood Park (Methodist Homes For The Aged) 19 Fulwood Park Liverpool Merseyside L17 5AD Lead Inspector Daniel Hamilton. Key Unannounced Inspection 12th November 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 Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.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. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fulwood Park (Methodist Homes For The Aged) Address 19 Fulwood Park Liverpool Merseyside L17 5AD 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) 0151 727 3840 kathryn.rafter@mha.org.uk home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Ethel Markey Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2007 Brief Description of the Service: Fulwood Park is owned by Methodist Homes, a national charity. The home is registered to provide personal care and support for up to 34 older people. The home is a large detached house standing in attractive landscaped gardens in the Aigburth area of the city. The home is accessible via a ramp at the front entrance and is fitted with a passenger lift. A call bell system is installed throughout the home. The accommodation comprises of 33 single bedrooms with en-suite facilities and 1 bedroom without an en-suite. There are two lounges, a spacious dining room and a hairdressing room. Assisted bathing facilities are also available. The home has a main laundry and a resident’s laundry to encourage independence. Tea making facilities are available on each floor for residents and visitors use. There is a designated area for car parking at the front of the home. Care Home Fees range from £378.00 to £490.00 Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately 9 hours. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were viewed and the Registered Manager, Assistant Managers, staff and residents were spoken with during the visit. Survey forms were also distributed to a number of staff, residents / or their relatives prior to the inspection, to obtain additional feedback about the home. All the key standards were assessed and progress / action taken in response to the previous recommendations from the last key inspection in February 2007 was reviewed. What the service does well: Residents spoken with during the visit complimented the service and the standard of care provided. For example, one resident reported; “There is no place like home but I have been made to feel welcome. The staff are extremely kind and helpful”. Likewise, a relative reported; “Staff treat each person as an individual. There is little or no sense of it being an institution.” A Statement of Purpose, Service User Guide and a Residential Contract had been developed in order to provide information on Fulwood Park for residents and / or their relatives. Likewise, a comprehensive assessment and care planning system had been established which enabled the staff to identify the health, personal and social care needs of residents and to plan a personcentred service. Residents confirmed that they had access to health care practitioners subject to individual need and medication was appropriately managed. Staff spoken with demonstrated knowledge and understanding of the principles of good care practice and residents confirmed that they felt valued and treated with respect. Comments from two residents included: “The people who work here are more like friends” and “The staff are good hearted and try to do their best for you.” The general atmosphere in the home was warm and friendly and one resident reported that “Visitors can call at any time.” Residents confirmed that they were able to exercise choice and control over their lives and follow their Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 6 preferred routines. The home had an activities coordinator and a programme of activities had been developed in consultation with the people using the service. Menus identified that a range of nutritious and wholesome meals were provided to residents and the people using the service complimented the standard of catering. Comments included; The meals are very substantial and we can have alternative choices” and “The food is top quality.” Policies and procedures had been developed to ensure a satisfactory response to complaints and adult protection issues. Records showed that complaints had been listened to and acted upon and no issues of concern were received during the visit. Systems had been established to ensure staff were correctly recruited, inducted and trained to ensure competency in their role. Likewise, quality assurance systems were in place to ensure the service was run in the best interest of the people using the service. What has improved since the last inspection? What they could do better: Some of the care / support plans examined did not clearly identify the desired support outcomes. This matter should be addressed to clarify individual objectives. Furthermore, the staff should ensure that the details of all chiropody appointments are recorded on health care records to provide an audit trail. The manager should complete a National Vocational Qualification in Care at Level 4 so that she has the necessary qualifications for her role. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.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. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.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 Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information on the service and the needs of the people living in the home had been developed to enable prospective residents and their families to make an informed choice regarding the suitability of the service. EVIDENCE: A Statement of Purpose and Service User Guide had been developed in a standard format to provide information for prospective residents and / or their relatives on the service and facilities provided at Fulwood Park. Copies of the documents were displayed in the reception area of the home and also provided to prospective residents and / or their relatives as part of a welcome pack. The personal records of four residents were viewed during the visit. Each file contained a copy of a ‘Domiciliary Assessment’ together with other supporting documentation that had been completed by the manager and / or senior staff within the home. Records detailed that Domiciliary Assessments had been undertaken prior to residents being admitted to the home so that the needs of prospective residents were identified and planned for. Equality and diversity Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 10 issues had been taken into consideration as part of the assessment and care planning process. For example, information on each resident’s religion, ethnicity, cultural and dietary needs had been obtained. The manager reported that copies of assessments completed by care managers from within Social Services and / or the Health Authority would also be obtained for reference, subject to their availability. Feedback received from residents and / or their representatives via Care Home Surveys and discussion confirmed people had received information on the home and a copy of a ‘Residential Contact’ was available on files, which outlined the responsibilities of all parties and what was included in the fees, etc. Fulwood Park does not provide intermediate care. Therefore, Standard 6 is not applicable. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A comprehensive care planning system had been developed and medication was well managed. This ensured staff understood how to meet the health and personal care needs of residents. EVIDENCE: A random sample of four resident’s files was undertaken as part of a casetracking process. Each file viewed contained a ‘Support Plan’, which had been prepared for individual residents following admission to Fulwood Park. Plans outlined the ‘identified needs’, ‘support required’ and ‘support outcomes’ for individual residents. The ‘Support Plans’ were generally completed to a good standard and reviewed on a monthly basis. Some outcomes recorded by staff were vague and examples were discussed with the Registered Manager during the visit. Additional documentation had been completed as part of the care planning process. This included a range of risk assessments that addressed: Waterlow (skin integrity); Nutrition; Moving and Handling; Falls and / or Person Centred Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 12 issues. Furthermore, personal profiles and daily, accident and health care records were in place. Discussion with residents and examination of health care records viewed provided evidence that residents had accessed a range of medical practitioners including: doctor, hospital, physiotherapy, district nurse, optician and chiropody appointments. It was noted that some chiropody appointments had not always been recorded and this was brought to the attention of the manager. The Annual Quality Assurance Assessment for the service detailed that the Provider had developed a Medication Policy. Staff spoken with confirmed they had read the organisation’s Medication Policy and local procedures were available in the medication file for reference. Staff responsible for the administration of medication reported that they had completed in-house and external medication training before they were authorised to administer medication. Furthermore, competency assessments had also been undertaken by the manager, to ensure staff understood their role and responsibilities when handling medication. At the time of the visit, only two residents were self-administering their medication. Risk assessments had been completed to ensure the health and safety of the residents was safe-guarded. Fulwood Park used a monitored dosage system that was dispensed by a local pharmacist. Systems had been established within the home to ensure medication was administered, recorded and stored in accordance with best practice. Records were also in place to account for medication returned to the pharmacist. Staff spoken with during the visit demonstrated knowledge and understanding of the principles of good care practice and confirmed they had received training in this subject as part of their induction training. Staff were observed to offer appropriate support to the people using the service during the day and residents spoken with were complimentary of the staff team and confirmed they were valued and treated with respect and dignity. Comments included; “The staff are pleasant” and “There is no place like home but I have been made to feel welcome. The staff are extremely kind and helpful.” A relative reported. “Staff treat each person as an individual. There is little or no sense of it being an institution.” Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Meals, activities and routines were flexible and varied to enable the people using the service to have choice and control over their lives. EVIDENCE: Records were in place which contained information on the lifestyle, recreational and dietary needs / preferences of the people living in the home. An ‘Activities Coordinator’ was also employed at Fulwood Park, to organise and facilitate a range of activities in consultation with residents. The Activities Coordinator demonstrated knowledge and experience in organising activities for older people and had links with the ‘National Association of Patient Activities’ (NAPA), which is a national organisation that promotes activities for residents in all residential, health and day care settings. A monthly programme of activities had been developed. Activities for November 2007 included: Hairdressing; Volunteers Shop; Gentle Exercises; Hand and Nail Care; Hymn Singing; Holy Communion; Painting For Fun; Memory Box; Reading Hour; Reminiscence and Chat; Craft Class; Residents Quiz; Crosswords; Board Games; knitting group; Poetry Reading and Listening to Music etc. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 14 Records of activities and participants were not up-to-date at the time of the visit. Feedback from residents and / or their representatives confirmed people were generally satisfied with the range and frequency of activities provided. Some residents expressed concern that activities in the home were sometimes cancelled due to staffing shortages. This was discussed with activities coordinator during the visit. Methodist ministers visited the home to provide Communion and Sunday services. Likewise, a representative from the Roman Catholic denomination visited a resident to provide Communion. The general atmosphere of the home was warm and friendly. Residents spoken with confirmed they were able to exercise choice and control over their lives, follow their preferred routines and receive visits from family and friends during the day. Residents reported that they were able to entertain their visitors in one of the communal lounges or in their own rooms and one resident stated: “Visitors can call at any time.” Staff spoken with demonstrated a good awareness of the rights and diverse needs of the people using the service and rooms viewed had been personalised by residents and contained photographs, ornaments and other memorabilia. The home had a three-week rolling menu, which provided a range of nutritious and wholesome meals for residents. A set range of alternative choices was also listed. Additional refreshments were served during the day. Meals were served in the home’s dining room at set times. Tables were equipped with tablecloths, napkins, placemats and condiments. Staff were available to offer support to residents as required in a discrete and unobtrusive manner. Residents spoke highly of the standard of meals provided. Comments included; “The food is top quality”; “The meals are very substantial and we can have alternative choices” and “The food is very eatable.” The kitchen areas were clean and tidy, and appeared well managed. The Cook reported that the service would cater for different health, cultural and / or dietary needs upon request. Designated ‘Tea Bay’ areas were also available within Fulwood Park where residents could prepare light refreshments as and when required. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems had been developed to listen and respond to complaints and to protect service users from abuse. EVIDENCE: The Registered Provider had produced a Complaints Policy and Procedure to enable residents and / or their representatives to understand the process to follow when making a complaint. A copy of the Complaints procedure was clearly displayed within Fulwood Park for people to view. Records detailed that three complaints had been received since the last inspection. Two of the complaints were made by the relatives of two residents. The first concerned missing property and the second was in regard to the notice period given to clear a room. The third complaint was made by a resident and concerned the conduct of a member of staff. Records showed that all the complaints had been acknowledged and responded to by the manager. Furthermore, feedback received from residents confirmed they had no complaints about the service and were confident that the manager and / or senior staff would listen and act upon any issues of concern. Comments received from residents included; “It’s very nice. I’ve no complaints and I’m well cared for” and “In my opinion there is nothing to complain about.” There had been no complaints to the Commission for Social Care Inspection since the last visit. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 16 Policies and procedures were in place to ensure a satisfactory response to suspicion or evidence of abuse. Records detailed that staff completed training in the Protection of Vulnerable Adults as part of their induction and also received annual refresher training in this subject. Staff spoken with demonstrated a satisfactory understanding regarding the different types of abuse and reporting procedures. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment at Fulwood Park is pleasant and well-maintained. This provides the people using the service with a safe, clean and comfortable home. EVIDENCE: Fulwood Park employed two part-time maintenance personnel who were responsible for general maintenance and repair. Contractors were hired for major and specialised work as and when required. The organisation also had access to an estates management team who were available for guidance and assistance. An ‘Annual Repairs, Renewals and Decoration Plan’ had been developed for Fulwood Park, to ensure the environment received ongoing maintenance and refurbishment as required. The manager reported that since the last visit ‘Tea Bay’ areas had been refurbished and the cupboards fitted with magnetic locks. Furthermore, the Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 18 dining room had been fitted with a new non-slip floor covering and the sun lounge, television room and laundry had been repainted. The location and layout of the home was suitable for its stated purpose (please refer to the ‘Brief Description of the Service’ section for more information on the premises). Residents were observed to have access to personal mobility aids, subject to individual needs. Systems had been established to monitor the condition of the environment and to ensure hazards were identified and controlled. Health and Safety checklists were also completed periodically to ensure best practice. Overall, areas viewed during the visit appeared to be safe and maintained to a good standard. Likewise the gardens were tidy and attractive. One person reported; “Living here is a dream. I love it.” The home had three domestic staff and a laundry assistant. On the day of the unannounced inspection, the home was clean and did not have any malodours. The Annual Quality Assurance for the service detailed that a policy on communicable diseases and infection control was available for reference and records showed that staff completed training in hygiene / infection control as part of their induction training. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The welfare of the people using the service is safeguarded as staff are appropriately recruited and receive induction and ongoing training to ensure competency in their role. EVIDENCE: Examination of staffing rotas and discussion with the manager and staff confirmed there had been no changes to the staffing levels since the last inspection. Rotas detailed that an assistant manager and four carers were on duty from 7.00 am until 12.00 pm. One assistant manager and three carers worked from 12.00 pm until 10.00pm and two care assistants were on waking night duties from 10.00pm until 7.15 am. The manager generally worked from 9.00 am to 5.00 pm during the weekdays (or as required by the service) and an activity organiser worked 5 days per week from 7.00 am until 3.00 pm. Residents spoken with were complimentary of the staff team and confirmed that staff were available when needed. Comments included; “The people who work here are more like friends” and “The staff are good hearted and try to do their best for you.” Some staff reported concerns regarding staffing levels via survey forms and this issue was brought to the attention of the manager during the visit. The manager agreed to look into the issues raised. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 20 The Registered Provider had developed a corporate Recruitment and Selection procedure, which covered equal opportunities. The Registered Manager maintained responsibility for coordinating all aspects of recruitment and the Organisation’s head office in Derby was responsible for confirming the outcome of Protection of Vulnerable Adult (POVA) and Criminal Record Bureau (CRB) checks. A vacancy existed for one night staff and a kitchen assistant at the time of the visit. The manager reported that 5 staff had commenced employment in the home since the last inspection. The recruitment records for the five staff were viewed. Each file contained the necessary records required under the Care Home Regulations 2001. Examination of training records and discussion with staff confirmed staff completed a range of induction and ongoing training. This included a ‘Learn to Care’ modular programme, a detailed induction booklet developed by the Provider and ‘L Box’ training to ensure the requirements of the Common Induction Standards were met. Records revealed that staff were also supported to complete additional training that was relevant to their roles including; Protection of Vulnerable Adult, Safe Working Practice and National Vocational Qualifications in Care. The manager reported that the home employed 19 care staff. This number included three assistant managers and a senior. Documentary evidence was available to confirm that 14 (73.68 ) of the staff had a National Vocational Qualification in Care at level 2 or above. One member of staff was working towards a National Vocational Qualification at the time of the visit. Training records had been signed by staff as recommended at the last visit to confirm staff had attended each session. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and administration systems had been established to ensure the home was safe and operated in the best interests of the people using the service. EVIDENCE: Fulwood Park is managed by Mrs Ethel Markey who is registered with the Commission for Social Care Inspection. Mrs Markey has managed the home for over two years and had previous management experience in residential care for older people. Previous inspection records confirm that Mrs Markey has completed the National Vocational Qualification (NVQ) level 4 Registered Managers Award. At the time of the inspection the manager had not completed a NVQ level 4 in Health and / or Social Care. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 22 Records showed that the manager had completed a range of training that was relevant to the management of a care home for older people and that Mrs Markey had continued to undertake periodic training that was relevant to her role. Residents spoke highly of the care provided and management systems and processes had been established to ensure the service operated in the best interest of the people using the service. Records showed that staff received formal supervision to support them in their role and there were clear lines of accountability both within the home and to senior management. The Methodist Homes for the Aged (MHA) group commissioned an external organisation (TMC) to undertake an annual quality assurance audit each year in addition to the home’s internal quality assurance systems. This enabled the service to monitor its performance and residents’ satisfaction levels. This was last completed for Fulwood Park during August 2007. The findings were collated and compared against similar services within MHA. The outcomes were discussed with residents and staff and formed the basis of an action plan for the home. Internal Quality Assurance Audits were also undertaken by the home twice each year to focus on topics from the Provider’s Quality Standards Manual. This was last completed in May 2007. Resident Meetings were also coordinated each month to enable the home to consult and seek the views of residents. A suggestion box was also available in the hallway to enable residents and their representatives to share their views in confidence. The Organisation had developed a financial management procedure to provide guidance to staff. The manager did not act as an appointee for any of the people living in the home at the time of the visit. The manager looked after the personal spending money for twenty-six residents. Records of financial transactions were maintained that detailed how the money was spent and receipts were obtained to account for expenditure. Secure facilities were available for the safekeeping of money. The Annual Quality Assurance Assessment for the service detailed that Health and Safety policies and procedures were in place and that test, maintenance and / or associated records were up-to-date for all key areas. Staff had access to safe working practice training as part of their ongoing training and development within the home and health and safety audits were undertaken on a regular basis. Fire records were checked during the inspection and these were found to be in good order. A fire risk assessment and certificates were also in place to confirm the fire alarm system and extinguishers had been serviced. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 4 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 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP7 OP8 OP31 Good Practice Recommendations Support plans should be reviewed to ensure they clearly describe the desired outcomes. Staff should record the details of Chiropody appointments on health care records to provide a clear audit trail. The manager should complete a National Vocational Qualification in Care at level 4 to ensure she has the necessary qualifications for her role. Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG 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 Fulwood Park (Methodist Homes For The Aged) DS0000025389.V349970.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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