Inspection on 12/06/06 for Mersey Parks

This inspection was carried out on 12th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Mersey Parks 22/09/09

Mersey Parks 30/10/07

Mersey Parks 04/12/05

Mersey Parks 28/06/05

Mersey Parks 28/02/05

Mersey Parks 27/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mersey Parks 99 Mill Street Liverpool Merseyside L8 5XW Lead Inspector Jeanette Fielding Key Unannounced Inspection 12th June 2006 10:30 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 Mersey Parks DS0000025196.V291588.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. 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. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mersey Parks Address 99 Mill Street Liverpool Merseyside L8 5XW 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 709 4791 www.bupa.com BUPA Care Homes (CFHCare) Limited Care Home 150 Category(ies) of Dementia - over 65 years of age (90), Old age, registration, with number not falling within any other category (60) of places Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 29 DE/E and 1 named DE aged under 65 years (N - Greenbank House) 30 DE/E (PC - Sefton House) 29 OP and 1 named person aged under 65 years (PC - Princes House) Only 29 DE/E and 1 named DE under 65 years (PC - Stanley House) Only 27 OP and 3 named persons aged under 65 years (N - Springfield House) 4th December 2005 Date of last inspection Brief Description of the Service: Mersey Parks is a purpose built home, built approximately fourteen years ago. The home comprises five separate buildings, each having a separate management and staff structure. The home is registered to provide care for people aged over 65 years. Springfield House provides general nursing care, Princes House provides personal care, Greenbank House provides nursing care for elderly people with dementia and Sefton and Stanley Houses provide personal care for elderly people with dementia. Each house provides thirty bedrooms together with lounge and dining areas. Mersey Parks is close to local shops and amenities and is located within a short car/bus ride to Liverpool City centre. The fees charged by the home are in line with those paid by Local Authorities. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days and a total of 17 hours were spent in the home. The inspection was conducted in each of the five houses. Care plans were inspected and were found to contain the necessary information to ensure that individual care needs were identified and provided. Staff records were inspected to ensure that all checks had been made on staff to ensure the protection of service users. Service users, relatives and staff were spoken to, to obtain their views of the home and a questionnaire was provided for service users or relatives to complete as they wished. A tour of the premises was undertaken to assess the quality of the environment for service users. Considerable improvements have been made in all areas since the last inspection. What the service does well: What has improved since the last inspection? 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. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 6 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 Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 7 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): 1, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed pre-admission assessments are undertaken on all prospective service users to establish their care needs and thereby enable staff to meet their needs. EVIDENCE: A detailed statement of purpose, and service user guide, have been prepared to give full information to current and prospective service users. These documents give details of the facilities and services provided by the home. Improvements have been made to the majority of pre-admission assessments on prospective service users. The care files of service users admitted to each house were inspected to evaluate the information gathered prior to the service users admission to the home. Stanley House. The pre-admission assessments contain full information regarding the service users social and care history. Information had been Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 8 gathered from the service users, where possible, and also from relatives, hospital staff and any other person involved in their care. Details were also recorded of how the service users dementia was displayed and of the specific care that had been given in the past. Princes House. The pre-admission assessments on service users were quite good. A history of the service users life experiences had been recorded together with their specific care needs. One service user had been admitted who suffers from diabetes but the staff had failed to obtain the date that the service user had been seen by an optician. This is particularly important for service users who have diabetes to ensure that eye problems which are caused by diabetes are identified in the early stages. Information had been gathered from service users, their relatives and other healthcare professionals. Sefton House. Assessments had been undertaken by one of the senior members of staff to evaluate the service users care needs. Information had been gathered from relevant persons, however, it is evident that for one service user, the home had not been given full information. Some care management problems have identified since the service user has been admitted to the home. This has resulted in the staff having to spend additional time evaluating the service user specific problems which may have resulted in the service user, or other service users being placed at risk. This is certainly not due to the member of staff’s assessment but by the lack of information given at the time of the assessment. Greenbank House. Qualified nurses undertake pre-admission assessments on service users who are accommodated in this house. These were generally good and it was evident that information had been gathered from appropriate persons involved in the service users previous care. Mental health assessments are made to evaluate the degree of dementia suffered by the service users so this can be taken into account when planning the care for each service user. Springfield House. There have been great improvements in the assessments made on new service users to this house. Full information is now gathered and comprehensive records are held. All nursing needs are identified together with social care needs. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 9 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements in the care plans now ensure that staff have full information to enable them to meet the needs of the service users. Medications are dealt with to a good standard to promote good health and protect service users. EVIDENCE: Care plans are prepared for each service user on admission using the information gathered at the pre-admission assessment. These are agreed by the service user or, where agreed, their representative who sign the plans to indicate their agreement. The plans are further developed following admission through regular reviews to ensure that the service users changing needs are identified and that the appropriate level of care can be given. The resident’s health is monitored and appropriate action taken. The home seeks professional advice on health care issues, acts upon it and generally is able to provide the aids and equipment recommended. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 10 A total of 21 care files were inspected within the five houses to evaluate the level of care required and the daily reports were assessed for evidence that the required level of care was given. Stanley House. The care files in this house were excellent. Clear and informative plans were in place to enable staff to identify the care needs of each individual service user. Risk assessments had been made on all service users and appropriate measures put in place to remove or reduce those risks. Staff spoken to during the inspection confirmed that they were given full information about the service users and were supported to meet those needs. The care plans had been reviewed on a regular basis and appropriate changes to care needs had been made where necessary. An audit on falls was being prepared to identify any risk areas within the house to further protect service users. Princes House. The care files in this house need additional information to be recorded. The record of visits made by other healthcare professionals was not clear and so it was difficult to establish when the dentist, optician and chiropodist had visited each individual service user. No record was held of visits by the Diabetic Nurse or of visits to clinics for those service users who suffered from diabetes. The daily reports written by staff lacked details of the actual care given or of the activities of daily living of the service users. The majority of entries in the daily reports referred to food and sleep and did not give an overall picture of the service users’ lives, activities or the care given. These files would benefit from additional information being recorded to demonstrate how the home is meeting their assessed needs. Sefton House. The care files in this house require additional information to be recorded to ensure that the needs of the service users are met. The care file for one service user did not contain a moving and handling risk assessment. No height or weight of the service user was recorded and this has the potential for placing the service user and the staff at risk if the appropriate method of moving the service user is not used. Assessments for moving and handling of one service user had been assessed but the general assessment identified that one member of staff would be needed to assist the service user but the plan of care identified that two staff would be needed. Staff must ensure that the appropriate information is recorded. One service user is reported in the plan of care to be aggressive, both verbally and physically, and has a history of harming themselves. No plan has been prepared to inform staff of the situations that may trigger these events or of the action to be taken to protect the service user or themselves, or of what diversional techniques that are effective to aid the service user. Greenbank House. The care files in this house are generally good. Risks have been identified and appropriate measures have been put in place to reduce or remove those risks. There is evidence that the care plans have been reviewed on a regular basis and the care plans have been amended or re-written to Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 11 ensure that the service users changing care needs are met. Two service users are reported in the daily reports to have slept in armchairs on several occasions at night. This is the service users choice, however, the files would benefit from additional information regarding this and the specific encouragement that staff should give with regard to them sleeping in their beds. The accident book records a high number of falls in this unit and it is necessary for a full audit of falls to be undertaken. This audit should take into account the time, the place and the condition of the service user at the time of the fall to ensure that the falls are not due to any other reason other than their medical condition. The advice of the GP should be sought where it is suspected that the service users medical condition is contributing to the falls. Risk management strategies should be implemented when the specific risk is identified. There appeared to be some lack of communication between senior staff in this house. A task had been requested of one member of staff who had not addressed this in a timely manner. As a result, one service user failed to meet a pre-arranged appointment resulting in delays through a rearrangement of date of that appointment. Care must be taken to ensure that full information is given to all staff and action taken in a timely manner. Springfield House. There have been great improvements in the care files in this house. The files inspected were all found to contain detailed information regarding the service users care need. Risk assessments have been undertaken and appropriate risk management strategies put in place. Full information is now recorded of the care required to wounds and of the progress of the treatment of those wounds. Care files all contained regular reviews of the care needs of the service users and full information regarding changes in care were accessible to the staff to ensure that the needs of the service users are met. The medications are dealt with individually by the staff in each house. The home has a policy and procedure for the administration and handling of medications which is accessible to all staff. Arrangements have been made for the disposal of medications which are no longer required and a contract for this is in place. It was found that the medication rooms in all houses were excessively hot which may affect some of the medications stored. The rooms should not be held at temperatures above 25c. It is recommended that thermometers with a minimum and maximum temperature measure be provided for all medications refrigerators where they are not currently provided to ensure accurate measurements. It is also advised that information be recorded on care or medication records of the occasions when PRN (as and when required) medications are to be administered to those service users who are unable to express their need due to their cognitive impairment. All medications rooms were found to be clean and well organised. Stanley House. The medications in this house were found to be dealt with in accordance with the homes policy and procedure. All records were accurate and up to date. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 12 Princes House. The medications in this house were found to be dealt with in accordance with the homes policy and procedure. All records were accurate and up to date. Sefton House. The medications in this house were generally dealt with in accordance with the homes policy and procedure. One medication which is to be given at least half an hour before the first food or drink of the day was being given at 10am, after breakfast. Another medication which is required to be given before meals was being given after meals. The home should clarify this information with the GP and pharmacist and change the administration times of those medications accordingly. Greenbank House. The medications in this house were generally dealt with appropriately. Hand written entries on the Medication Administration Record sheets should be witnessed to ensure the accuracy of the entry and the number of tablets, or amount of liquid medication, should be recorded also. Springfield House. The medications in this house were found to be dealt with in accordance with the homes policy and procedure. All records were accurate and up to date. All service users are accommodated in single bedrooms. Staff in all houses were seen to knock on bedroom doors and to wait for an answer prior to admission. A large number of service users were spoken to during the inspection, together with visitors to the home. Some service users were not able to express an opinion of the home due to their medical condition or cognitive impairment. All service users who expressed an opinion of the home spoke highly of the staff and said that, although they were very busy, would do anything for them. One service user who had recently transferred from another home said that they were apprehensive about the move but that everyone had made them very welcome and were now settled. One visitor spoke highly of the care afforded to their relative. They said that the staff were lovely and were very caring. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities are arranged to enrich service users social opportunities. The dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: The home employs three activities co-ordinators to provide entertainment and social stimulation for the service users. A rota is prepared to ensure that all service users are given the opportunity to participate in group or individual activities. Activities include music, singing, games and quizzes. A mobile shop is taken around each house with sweets, toiletries and tights for service users to have the opportunity to choose their purchases. The home provides for the cultural needs of service users who do not speak English. The services of the Multi Cultural Society will be sought for translation purposes. Picture symbols have been prepared to enable this service user to choose from a range of options by the use of these cards. Special diets can be provided to meet religious or cultural preferences. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 14 Visitors are encouraged to visit the home and are welcome at any time, although the main gates to the home are locked at night. Access to the home when the main gates are locked are by contact with one of the houses through an intercom system on the gates. Meals are prepared in the main kitchen and are transported to the houses in heated trolleys. The meals are then served individually to service user from the small kitchens provided in each house. Service users may take their meals in the dining room or in their own bedroom as they wish. Service users have a choice of meals and the main meal of the day is served in the evening. Breakfast is served throughout the morning to enable service users to take it at a time of their choosing. A cooked breakfast is always available on request. The dining tables were attractively laid with cloths. Cutlery is placed on the tables immediately prior to the meal being served in those houses where service users have a cognitive impairment as part of the risk management strategy. The meals served on the days of the inspection all appeared appetising. Service users spoken to said that there was always a choice of meals and that a good range was offered. One service user said that she had put on weight since moving to the home and felt much better for it. She went on to say that there were some foods that she could not resist and often had seconds. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected from abuse through staff training on adult protection issues. EVIDENCE: The home is owned by BUPA Care Homes Limited who has produced a corporate complaints policy and procedure. Information on how to make a complaint is detailed in the Service User Guide and the Statement of Purpose, and is also displayed on notice boards throughout the home. The records held by the home provide evidence that complaints are now addressed appropriately. No complaints have been received by CSCI since the last inspection. Staff are given training on abuse and adult protection during their induction training. This is also updated on a regular basis during subsequent training. Staff spoken to during the inspection confirmed that they had been given training and all were able to demonstrate that they were aware of the procedure to follow in the event of abuse being suspected. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The décor and furnishings within the home are good to provide service users with a bright and pleasant area to live. A programme of maintenance and improvement continues to create a comfortable and safe environment. EVIDENCE: This home comprises five separate houses for service users with a central building comprising management, administration, catering, laundry and hairdressing services. The home is located on a large site which provides separate secure garden areas for service users from each house. The home employs maintenance personnel to attend to repairs, redecoration and maintenance. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 17 The home is well maintained considering the size of the home and the high number of persons accommodated although a few issues were identified as requiring attention during a tour of the premises. Stanley House. The corridors and communal areas in this house have recently been redecorated and the décor is bright and welcoming. There is a lack of orientation signs in this house and these are necessary to aid the service users who have a diagnosis of dementia. One problem was identified following the redecoration in that the colour of the toilet doors has been changed. Some service users continue to look for the blue doors to find toilets, but these are now light green. To resolve this problem for service users, new picture signs are to be fitted to doors to identify where toilets are located. These signs have been ordered and their delivery is awaited. In bathroom 37, the hot water pipe is exposed and requires to be protected to avoid the risk of burns to service users. The bath panel in this bathroom is damaged and requires to be replaced. A grab rail should be fitted in the shower cubicle in shower room 3 to assist service users. There was some malodour in this house which has been identified as a problem with the carpet in the corridor. Despite regular cleaning, the odour has not been removed and so arrangements are in place for this carpet to be replaced and this is due to take place at the end of June 2006. Princes House. This house was found to be well maintained and no issues were identified that require attention. A smoking lounge has now been provided for service users to provide a more pleasant environment for those service users who do not smoke. Sefton House. Some malodour was noted in two bedrooms in this house and was being addressed at the time of the inspection. Orientation pictures are also going to be provided in this house to assist service users to identify toilets. The linen room in this house held a box which contained a large number of items of clothing which was unlabelled, and some badly stained. Care must be taken to ensure that service users clothing is returned to them and all unwanted clothing is disposed of. The bath panel is bathroom 37 is damaged and requires replacement. The two sluices in this house were found to be malodorous and were unlocked. It is essential that sluices are locked at all times when not in use. The lounge and corridors of this home have recently been redecorated and are bright and welcoming. Greenbank House. This house was found to be well maintained and no issues were identified that require attention. Springfield House. The bath panel in bathroom 33 is damaged and requires repair or replacement. A smoking lounge has now been provided for service users to provide a more pleasant environment for those service users who do not smoke. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 18 Some of the secure gardens on the site were found to be overgrown and require attention. Staff in Stanley House have been working with service users to plant some flowers in the central raised area and in pots. This area is particularly attractive however the pathways require clearing and the shrubs trimmed to provide a safe area for service users. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs a well trained and enthusiastic staff team to meet the needs of the service users and ensure their protection. EVIDENCE: Each of the houses is staffed independently with a designated care manager to supervise the care provision. The staff rotas provide evidence that each individual house provides staff in sufficient numbers to meet the needs of the service users accommodated. The home provides qualified nurses in those houses that provide nursing care, and qualified care staff in the houses that provide personal care. All senior staff are supported by a team of care staff. The home also provides housekeeping, catering, maintenance and administration staff. All new staff are required to complete an application form prior to interview. A record is held of the interview. Two references are taken together with POVA and CRB checks. Evidence of qualifications and training are to be produced. All new staff are required to complete a comprehensive induction and foundation training programme and staff work with a work based mentor. A record of this training is held on their files. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 20 Records are now held of all training undertaken by staff. Recent training includes Fire, Abuse in the Elderly, Manual Handling, Care Planning, Administration of Medications, POVA, Quality in Dementia and COSHH. Further COSHH training is planned together with Continence and Supervision. NVQ training continues with 47 now having achieved this. The staff turnover at the home is low to provide a consistent approach to care. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home reviews aspects of its performance through a good programme of self review and consultations which include seeking the views of service users, staff and relatives. EVIDENCE: There has been a change in the manager of the home since the last inspection. The new manager is qualified and extremely experienced and an application to register the manager is to be submitted to CSCI. The manager was previously employed at another home operated by BUPA Care Homes (CHFcare) Ltd and was registered by CSCI at that home. The home provides service users with comment cards to enable them to express their views of the home. Comments are welcomed from service users, Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 22 their relatives and other visitors to the home and are available in the reception area. The majority of service users have their monies handled by their next of kin or an advocate. The home does not attend to the finances of any of the service users. The home can assist service users to open a bank account within a building society where they can be invoiced charges such as hairdressing or chiropody. Monthly visits are made to the home by the Responsible Individual, as required, and a report completed. All staff are made aware that they hold some responsibility for the health and safety matters within the home. All health and safety matters must be reported appropriately and the records show that these issues are addressed as a priority. A central fire log book is held that details all the fire alarm and emergency lighting tests for each of the five houses. These records were found to be well maintained. Tests are also made on the hot water temperatures to ensure that service users are not at risk from scalding. Safety certificates in relation to the fire alarm, emergency lighting, gas, hoists, electricity and portable appliance testing were found to be in order. Mersey Parks DS0000025196.V291588.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 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 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 Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? No 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. 4. Refer to Standard OP9 OP9 OP9 OP19 Good Practice Recommendations The registered person should ensure that the temperature in medication rooms is held at a maximum of 25c. The registered person should ensure Handwritten entries on MAR sheets are signed by two persons to ensure accuracy. The registered person should ensure minimum/maximum thermometers are provided in medication refrigerators where they are not currently provided. The registered person should ensure Garden areas are cleared to give full access to service users. Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Liverpool Local Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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. Extracts may not be used or reproduced without the express permission of CSCI Mersey Parks DS0000025196.V291588.R01.S.doc Version 5.1 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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