CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65
Hemsworth Park Care Centre Wakefield Road Kinsley Wakefield West Yorks WF9 5EA Lead Inspector
Tony Railton Unannounced Inspection 16th January 2006 08:15 Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 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 Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 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 and Care Homes for Adults 18 – 65*. 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. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Hemsworth Park Care Centre Address Wakefield Road Kinsley Wakefield West Yorks WF9 5EA 01977 617374 01977 610847 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) the.willows@ashbourne.co.uk Exceler Healthcare Services Limited Mrs Wendy Donaghey Care Home 93 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (30), Old age, not falling within any other of places category (39), Physical disability (54), Terminally ill (3), Terminally ill over 65 years of age (3) Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The 19 bedrooms registered for young physically disabled, specifically are bedrooms 1 to 9 and bedrooms 12 to 21, will be occupied by ambulant and not wheelchair dependent service users. Can provide accommodation and care for service users with Dementia over 65 years within the total of 39 places for older people. Can provide accommodation and care for service users with Dementia within the total of 54 places for service users with a physical disability. 22nd June 2005 2. 3. Date of last inspection Brief Description of the Service: Hemsworth Park Care Centre continues to provide personal and nursing care and accommodation for older people who may also suffer with dementia, this includes some who may also have a terminal illness. The home also provides personal care and accommodation for younger adults who have a physical disability. Set back in its own grounds the home has a large parking area to the front with a small garden or lawn area to the front and side. The home sits alongside Hemsworth Water Park a local beauty spot and some bedrooms to the rear of the home have views of the park ad surrounding countryside. This large home is split and operates as four separate units each having there own lounges, dining rooms, quiet rooms, toilets and bathrooms. The home has a passenger lift and assisted bathing facilities for those who require them. The home is close to local shops including a post office, public houses and community centre. It is also on a main bus route and Hemsworth Town centre and all facilities and amenities is only a few minutes journey. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This home is inspected against the National Minimum Standards for both Older People (OP) and Younger Adults(YA); reference to each may be made throughout the inspection report. The inspector arrived early for this unannounced inspection and took the opportunity to observe the morning routines in the home. This was a very positive and enjoyable inspection and a number of improvements were noted. There was the opportunity to speak to some residents in the younger disabled unit on the lower floor. Unfortunately an outbreak of Scabies prevented a proper inspection of the upper floor but most of the core standards have been previously inspected. There was, however, the opportunity to speak to the general manager, care manager, unit managers, nursing and care staff, housekeeper, domestics and handyman. There was also the opportunity to look at residents’ case files including assessments, care plans, medical and daily records, and reviews. Staff training and supervision records were also seen and the medicine ordering, storage, administration and recording systems were checked. The inspector was pleased to note that the home continues to meet all statutory requirements, however, some outstanding recommendations were noted. The inspector would also like to take the opportunity to thank the residents and staff for their warm welcome, hospitality and patience throughout the inspection. What the service does well:
The home continues to provide a relaxed and comfortable environment for people to live in. Residents have their bedrooms as they want and most are surrounded by their own possessions. The shared spaces such as dining rooms and lounges are homely and comfortable. On the day of the inspection one dining room had all the tables set out with napkins, flowers and condiments. The tables presented very well indeed and this practice is to be commended. On the day of the inspection all areas of the home were observed to be clean and free from any unpleasant odours. The staff team and in particular domestic staff are to be commended for their efforts in maintaining such a good standard of cleanliness throughout the home.
Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 6 It was noted that one resident has been given a larger room to accommodate his care needs. He told the inspector that he was pleased with his room and that he had everything he needs. The care manager said that his room was previously a rehabilitation room with a small kitchen and lounge which have been converted and adapted for him. This practice is to be commended. Residents care plans showed that they have the opportunity to develop their own care plans and sign to say that they agree with them. It was noted that some care plans were signed by residents’ relatives if they could not sign themselves. Care plans continue to be reviewed on a regular basis. Staff recruitment and selection policies and practices make sure that residents are safeguarded and protected. Staff training records show that new staff receive induction and foundation training which reflects national sector skill council specification and timescales. What has improved since the last inspection?
The home is getting better at showing in the daily records that residents are making decisions about how they live their daily lives. There has been an increase in the use of descriptive words in the daily records to reflect and show residents’ choices preferences, likes and dislikes. The inspector noted that there appeared to be more staff on duty than on previous inspections. The manager care manager said that this is not the case however, the staff team is quite stable at the moment and that they are more experienced, relaxed and confident in their work. Staff said that they are happy and that they feel supported in their work. Staff were observed carrying out their duties in a relaxed and unhurried manner. On the day of the inspection all areas of the home were observed to be clean and free from unpleasant odours. The staff team and in particular the domestic staff are to be commended for their efforts in maintaining such a good standard of cleanliness throughout the home. The care manager said that there is now a programme of renewal, maintenance and decoration of the building and that this is discussed with the handyman and manager at a monthly update meeting. The minor remedial work in the two bedrooms identified following the last inspection have been carried out and at least two have also been redecorated. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 7 What they could do better: 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. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 (OP) & 3 & 6 (YA) Residents’ individual, personal and healthcare needs are assessed before they are admitted to the home EVIDENCE: Residents’ case records including assessments, risk assessments and integrated care management programs show that their personal and healthcare needs are assessed before they are admitted. The care manager said that each resident is met and assessed by someone from the home before they are admitted. A letter is then sent confirming that the home can meet individual residents health and care needs. Some assessments show that residents are fully involved in the assessment process as assessments and care plans are agreed and signed by residents’ wherever possible or their relatives. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 (YA) 7,14 & 33 (OP) Residents are supported an encouraged to make decisions about their lives and these are recorded in the care plans, reviews and daily records, however, some daily records are better than others and there is a need for a consistent approach. EVIDENCE: Some residents are very able and can give a good account of life in the home and about their assessments and care plans. Some residents can do lots of things for themselves and tell carers what they want to do. Others are less able and descriptive words are required in the daily records to reflect their choices and preferences and show when they make decisions about their daily lives.
Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 11 The home needs to be better at capturing what residents, their relatives and other visitors, particularly healthcare professionals, think about the quality of care provided by the home. The minutes of the residents meetings show that they are involved in the decision making processes in the home are consulted and participate in all aspects of life in the home. Residents assessments and in particular risk assessments show that they are encouraged to live as ordinary a life as possible. Some residents are very independent and choose to travel independently to local shops and public houses. The care manager said that all residents documentation including assessments and care plans are going to be changed and standardised within the coming year. The proposed documentation appears to be very comprehensive. The inspector looks forward to seeing some completed documentation in operation at the next statutory inspection. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 (YA) ,10,12,13 & 15 (OP) Some residents are very able and can choose what they want to do and where they want to go and use local community based leisure services. However, some residents would benefit from having activities organised to meet their individual leisure and recreational needs.
Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 13 EVIDENCE: Examination of service users case files including assessments, risk assessments, care plans and daily records show that residents leisure and recreational needs are assessed. However, discussion with residents and care manager indicates that although there is a programme of activities displayed on the notice boards some of the activities have not taken place. The care manager said that the home has been without an activities organiser for some time , however, arrangements have been made to provide an activities co-ordinator to work with groups and individual residents. The daily records show that some residents do make choices and decisions about what they do and how they live their daily lives. Photographs displayed on the walls suggest that there are some activities arranged for those who wish to participate, however, the general feeling is that residents would benefit from having more organised and appropriate activities. Discussion with residents, care manager, examination of the menus displayed on the notice boards and sampling of food show that residents do have a choice of menu. The menu choice lists show that residents are asked on a daily basis what menu they prefer. One resident said that the meals are always good. Another said that he enjoys the meals provided. Most residents are very able and can communicate their dietary needs to care staff. There was evidence of kitchen staff knowing individual residents likes, dislikes, choices and preferences and of residents choosing an alternative menu to that originally chosen. The housekeeper and her kitchen team are to be commended for their efforts accommodating residents choices and in maintaining such good standards of meal preparation in the home. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 (YA) 8,9,& 10 (OP) Residents personal healthcare needs are met by the home who co-ordinate community based healthcare professionals who visit the home on a regular basis. Residents are safeguarded and protected by the medicine ordering, storage, administration and recording policies and practices. EVIDENCE: Examination of some residents’ case notes including assessments, care plans, medical and daily records it was established that residents healthcare needs are assessed, planned for and met. It was also established that some residents have special medical care needs which are met by visiting specialists. Discussion with the care manager indicates that only qualified staff administer medicines and that there is a monthly audit of the medicine administration and recording systems. Examination of the controlled medicine storage
Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 15 administration and recording systems showed that residents are safeguarded and protected. The inspector noted that all of the assessment, care planning and medical record keeping is going to be standardised and all new documentation will be introduced this year throughout the home. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 (YA) & 16 & 18 (OP) Residents have a copy of the complaints procedure and have the opportunity to complain about the services provided. EVIDENCE: Discussion with residents, care manager and examination of the record of complaints show that residents are listened to and what they say is treated seriously and acted upon. The inspector was pleased to note that the home has a copy of the Wakefield Social Services and Health Multidisciplinary Adult Abuse and Protection Policy and Procedure. Staff training records also show that adult abuse forms part of the induction training for all staff. Observation of the interaction between residents and the staff team showed that residents are treated with dignity and respect at all times and that there are positive relationships fostered between residents and their carers. Examination of residents case files including financial records and discussion with the financial administrator and care manager shows that residents are safeguarded and protected by the homes financial policies, procedures and practices. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 30 (YA) & 19 & 26 (OP) Residents live in a home which is homely comfortable and clean. EVIDENCE: Only the core standards were inspected on this occasion. Just a sample of bedrooms, lounges and dining rooms were inspected. It was noted that on the day of the inspection all areas of the home were clean and free from any unpleasant odours. The manager and his staff team and in particular housekeeper and domestic staff are to be commended for their
Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 18 efforts in maintaining such a good standard of cleanliness throughout the home. It was noted that one young resident who suffers with Huntington’s has been accommodated in a larger bedroom to meet his particular care needs. The ‘double sized’ bedroom has been modified specifically for this resident who said that his room is “great” and that he has “everything” he needs. He also said along with the care manager that his mum is also very pleased with his room. One carer said that the room is much better as there is room to move around and use the hoist properly. This practice although probably a ‘one off’ is good and the manager and staff team are to be commended for accommodating and providing for this particular residents assessed care needs. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 19 Staffing
The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 & 36 (YA) & 27,28,29 & 30 (OP) Residents’ benefit from clarity of staff roles and responsibilities, however, staff may benefit by care staff having NVQ qualifications and from staff being appropriately supervised. Residents are protected by the staff selection and recruitment policies and practices. EVIDENCE: Staff training records show that most care staff are registered on National Vocational Qualification training, however, not many staff have completed their NVQ training. The care manager said that NVQ trainers and assessors are arranged by the organisation and in many respects out of the homes control. She went on to
Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 20 say that there is a need to meet minimum standards and make sure that at least 50 of care staff have a NVQ Level 2. Staff training records also show that staff have attended First Aid, Moving and Handling, Basic Food Hygiene and Dementia training this year. Notices on the notice boards show that further First Aid and Fire training has been arranged for those who require it. Examination of staff records show that appropriate checks including CRB and POVA (Protection of Vulnerable Adults List) are taken up before staff are employed in the home. Staff records also show that new staff receive induction training which reflects National Training Organisation specification. Discussion with the care manager indicates that the home continues to provide a Palliative Care Link Nurse who attends all of the local update meetings arranged by the Community Palliative Care Specialist Nurse Co-ordinator. Discussion with the manager indicates that all staff continue to be issued with the Codes of Practice and Conduct issued by the General Social Care Council. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 (YA) & 31,33,35 & 38 Residents’ benefit from living in a well run home which is open and inclusive and where they benefit from the ethos leadership and management approach of the home. However, the home needs to be better at capturing the views of residents, their families and other stakeholders and showing others the quality of care provided .
Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 22 EVIDENCE: The home is currently without a registered manager. The manager said that he has completed the application form, however, he is waiting for a cheque from the organisation before submitting it to the Commission for Social Care Inspection. The inspector reminded the manager that the home has been without a registered manager for some time and because of this does not meet statutory requirements. The inspector had the opportunity to ‘sit in’ the unit managers meeting to discuss any issues relating to the running of the home. The care manager said that a monthly quality assurance audit is undertaken to look at the quality of services provided. However, she went on to say that service users and relatives survey questionnaires although available have not been given out. The manager said that previously questionnaires have been available in reception for visitors to take and complete. He went on to say that a questionnaire needs to be developed and distributed to seek the views of other healthcare professionals, nurses and social workers who visit the home. The care manager said that the information gathered through quality assurance questionnaires will be collated and a report provided to reflect and show other peoples views on the quality of care provided by the home. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 4 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT Standard No Score 37 1 38 X 39 2 40 X 41 X 42 3 43 x 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Hemsworth Park Care Centre Score 3 3 3 x DS0000006188.V278957.R01.S.doc Version 5.1 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. 1 Standard YA37OP31 Regulation 8 (1)(a) & 9(1)(2)(3) A person shall not manage a care home unless he is deemed fit to do so. The completed application for the registered manager along with the appropriate fee must be submitted to the CSCI as soon as is practicable. Requirement Timescale for action The registered provider shall appoint an individual to manage 01/03/06 the care home where there is no registered manager. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 25 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 Refer to Standard OP12 YA14 YA32OP28 OP36YA36 OP33YA39 Good Practice Recommendations Opportunities for residents to participate in organised activities should be recorded to reflect their choices and preferences. Residents have access to and choose from a range of activities in house and community based and a record is made of their choices and preferences A minimum of 50 of care staff should have a National Vocational Qualification Level 2 or above. All staff should have a minimum of six line management supervision sessions per year with a record kept for inspection. The views of residents, their relatives and other stakeholders should be sought through quality assurance surveys. The information gathered should then be collated and a report provided to reflect other peoples views on the quality of care provided by the home and any action taken by the home as a result of their comments. Hemsworth Park Care Centre DS0000006188.V278957.R01.S.doc Version 5.1 Page 26 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
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