Inspection on 04/12/05 for Mersey Parks

This inspection was carried out on 4th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mersey Parks 22/09/09

Mersey Parks 30/10/07

Mersey Parks 12/06/06

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 Unannounced Inspection 4th January 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.V277759.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.V277759.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.V277759.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) 30 OP and 1 named person aged under 65 years (PC - Princes House) Only 30 DE/E (PC - Stanley House) Only 27 OP and 3 named persons aged under 65 years (N - Springfield House) 28th June 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. Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over four days and a total of 24 hours were spent in the home. There has been no stable management structure at this home for over one year which has resulted in a deterioration of the record keeping overall. A new manager was appointed in October 2005 and has identified the shortfalls. Some issues have been addressed and plans are in place to attend to all other matters. It is clear that considerable work is required to be undertaken by the manager and management team to bring the home back to the standard required by both BUPA and CSCI. During the inspection, service users, relatives and staff were spoken to in order to obtain their views of the home and of the service provided. The views given were all positive and both service users and their families said that they were happy with the care given. Records relating to the care of the services were inspected and found not to contain sufficient information. Assessments and care plans were inadequate although this is currently being addressed by the manager. Records relating to staff provided evidence that all checks are made to ensure that service users were protected, but evidence of ongoing training was not recorded. Again, the manager is aware of this and arrangements have been made for this to be dealt with. Inspection of the building showed that improvements have been made to the décor and facilities provided. What the service does well: Service users spoken to said that they were happy with the care and the staff team. The management systems now established within the home are providing effective and although improvements still need to be made, evidence of the plans to address them were in place. Maintenance issues are addressed as soon as they are raised. The home was found to be clean and all areas were organised and tidy. Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 6 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.V277759.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The pre admission assessments were generally poor resulting in a lack of information necessary to enable staff to provide the appropriate level of care. EVIDENCE: Many of the pre-admission assessments do not contain sufficient information to enable a plan of care to be prepared. BUPA documentation identifies prospective service users possible care needs under a range of headings. It is the role of the person undertaking the assessment to identify the specific needs to ensure that all health and social care needs are recorded. No record is held of the persons who give the information regarding the service user, particularly in situations where the service user does not have the ability or capacity to give accurate information on their behalf. An assessment of the service user is undertaken on admission to the home on a BUPA pro forma document. In some cases, these forms are fully completed and contain all the necessary information to enable a plan of care to be prepared. Some were found to contain inadequate information, particularly in relation to mobility and moving and handling. Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 9 Staff spoken to during the inspection were able to demonstrate that they were fully aware of service users needs, however, much of this information was not recorded and presents as a problem to those staff who work on the individual houses on a bank or agency basis and do not have a full history of the service users. The assessments for those service users who are accommodated due to their dementia should include a full mental health assessment, giving details of how their dementia is displayed. It is advised that staff be given training in information gathering, recording and that the pro forma used for assessments be reviewed to include specific questions regarding care needs. Information regarding the use of specific equipment should be included in the initial assessment to ensure that this equipment can be provided prior to the service users admission to the home. Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 Care plans are generally poor and have not been updated to reflect the changing needs of the service users thereby denying the staff the information necessary to meet service users needs. The systems for the administration, recording and disposal of medications are poor and potentially place service users at risk. EVIDENCE: Care plans were found to be generally poor in all areas of the home. The new manager has identified this and has already put a system of auditing the files in place. Princes House. A lack of information is recorded in care plans. One file refers to a service user having a pressure sore on their back, but does not give details of where about on the back or of the treatment and care to be given by staff. One service user has cream applied, but no information is recorded as to why or how often. Reference is made in one service users daily report of the district nurse attending to a dressing on the service users leg, but no information is given as to why. Care plans had not been updated on a regular basis and so it was difficult to establish the service users current condition. Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 11 Some risk assessments had not been undertaken, specifically with regard to the use of bed rails and falls prevention. Stanley House. The files in this house were generally quite good. These had been updated and included sufficient information for staff to provide the level of care necessary. Sefton House. The care plans in this house had been reviewed but did not contain all the necessary information. One service user had had three falls in the last month, and had fallen and suffered a fractured hip in November 2005. The falls risk assessment identified that the risk of falling was low which conflicts with the information recorded in the accident book. Two service users had recently lost an excessive amount of weight but no reason for this was documented, nor was any action recorded to deal with this. No information was available for staff with regard to service users who may become aggressive. No details were recorded of the triggers to the aggression or of diversional programmes or interventions that may be necessary for effective care management. Springfield House. The care plans in this house were found to be poor. Specific charts are in place for those service users at risk i.e. frequency of turning those service users who are nursed in bed and fluid balance charts. It was noted at 4pm that these had not been completed since the night staff had gone off duty at 8am. It is of great concern that staff are reliant on their memories for the completion of these charts, and especially as some staff had gone off duty at 2pm. These are to be completed at the time of the intervention. The daily reports, completed by qualified nurses, were also of great concern. One service users daily report began by the comment ‘safety maintained,’ when the next sentence in the report gave details of a fall. The comment with regard to one service user was that they were seated in the ‘day room’ so that the staff could observe them. It is of serious concern that the views of the service user were not taken into consideration with regard to where they were seated and that staff felt that ease of observation was of greater importance. Greenbank House. Again, the care plans in this house were found to be poor. Risk assessments for two service users in relation to falls were inadequate, inaccurate and had not been reviewed or updated. One service user, whose needs had evidently changed quite considerable had not been reviewed since July 2005. Staff spoken to were aware of the changes but the documentation did not reflect the changes in care needs or provision. Records are held of visits made to and by GP’s, district nurses and other health care professionals, although some visits by chiropodists, dentists and opticians often proved difficult to find within the files. Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 12 The new manager has spoken with staff regarding accurate record keeping and has set time scales whereby all service users must be reviewed and the files updated to reflect health and social care needs. Considerable action is required with regard to medications. Excess stocks of medication awaiting destruction were seen in all houses. These medications were not stored securely with detailed records of those medications awaiting destruction. During the inspection, discussion took place with the manager regarding the medications and arrangements were being made with a company for the regular collection and disposal of medications. Arrangements were also put in place during the inspection for all medications awaiting collection to be stored securely. Concerns were expressed to the manager with regard to the procedure followed by staff for the administration of medications. A new policy and procedure has been prepared by BUPA and the manager said that she would ensure that copies of these documents were made available to all staff. Discussion also took place with the manager regarding medications prescribed on an ‘as required’ basis (PRN). Greater information needs to be recorded in service users files regarding the occasions when these medications are administered, the dose and frequency of the medications and greater detail regarding their use when service users do not have the ability to request them. Princes House. The keys to the medications were seen to be held in the drawer of the office. These keys are the responsibility of the person in charge of the house and must be held on their person. Some medications were signed for by staff to indicate that they had been administered but were still present in the packs, whereas others appeared to have been administered, due to their absence, but had not been signed for. Stanley House. Medications were handled well by staff. Sefton House. The medications administration record sheets were found to be in a poor condition in this house. Some medications were signed for by staff but had not been administered and a count on one medication clearly showed that it had been signed for but not given on at least four occasions. This was clarified by the fact that 14 tablets had been prescribed and delivered to the home, 14 signatures were placed on the MAR sheets, but 4 tablets remained in the packet. One medication, Fosamax, is required to be given prior to any food, drink or medication in the mornings and this information is clearly detailed on the MAR sheet. From the signatures on the MAR sheet and the discussion with staff, it is evident that this medication has been given at 10am following food and drinks. Appropriate training is to be given to all staff in this house who are responsible for the administration of medication. Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 13 Springfield House. In this house, again Fosamax was being administered at 10am to one service user, following food and drink, despite the information regarding administration of the medication being clearly detailed on the MAR sheet. Greenbank House. The MAR sheets in this house contained blank spaces where nurses have failed to sign to indicate that service users have taken their medications. Handwritten entries on the MAR sheet should be signed by two persons to confirm that the information, service user, drug and dose are accurately recorded. The MAR sheet for one service user records that medications are refused on a regular basis. There was no record that this refusal had been discussed with the service user or the GP. Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 14 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 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 service users with stimulation and social activity. Service users and staff spoken to said that there was insufficient activities, particularly for those service users who are confined to bed. Activities include singing and games and the co-ordinators also take a mobile shop around each house with sweets, toiletries and tights for service users to purchase. Each house has a designated time for activities and these are displayed in the houses and also in the reception area. The home is working to provide the cultural needs for one service user who is due to be admitted who does 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. 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 Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 15 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. Additional care should be taken when transporting meals to bedrooms by the use of trays and plate covers. The tables used in bedrooms for meals must always be cleared of other items prior to the meal being served. 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 dementia as part of the risk management strategy. Some chipped crockery was noted in Princes House and this was removed during the inspection. Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 16 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 Staff have a good knowledge and understanding of Adult Protection Issues which protects service users from abuse. EVIDENCE: The home is owned by BUPA Care Homes Limited who have 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. It is evident that complaints have not been made to the home, but directly to CSCI during the last twelve months as only one has been made to the home and four to CSCI. This may have been due to the lack of a registered manager at the home, however, the complaint received by the home was addressed appropriately. The inspector was advices that training is given to all staff regarding the different types of abuse and of the action to be taken in the event of it being suspected. Evidence of this training proved difficult to find due to the lack of information held on staff files. This issue is currently being addressed by the new manager. Staff spoken to during the inspection were able to demonstrate that they were aware of the action to be taken to ensure the protection of service users. Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Recent investment has improved the appearance of this home creating a homely and comfortable 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 employs maintenance personnel to attend to repairs, redecoration and maintenance. A new shower has been installed in one house to aid those service users who have difficulty getting in and out of the bath. Consideration is also being given to the installation of showers in houses where this facility is not currently provided. Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 18 A number of minor maintenance issues were identified during the inspection and were dealt with during the course of the inspection. It was evident that the maintenance staff work hard to keep the home in a good condition, however, their work would be made easier if an effective communication system were to be set in place. Some of the houses have a maintenance book but communications could be improved by the use of a book in all the houses where the maintenance personnel could access the information and sign to indicate that they have done so. Some damaged furniture was noted within the home but discussion with the maintenance staff confirmed that replacement furniture had been ordered and its delivery was awaited. It is strongly advised that the head of each house undertake a full inspection of their house on at least a weekly basis to ensure that all maintenance issues are identified and that all provisions are in place. The home is now providing boxes with glass covers outside bedrooms to enable family members to insert pictures and memorabilia to assist service users in identifying their own rooms. These are called ‘memory boxes’ and were seen to contain pictures and photographs of the individual service users together with small items that assist with orientation. Staff spoken to said that these had proved very successful, particularly for those service users who have some degree of memory loss. It is evident that improvements have continued to take place within the home and the home is bright and welcoming. All areas of the home were clean and no unpleasant odours were identified. Mersey Parks DS0000025196.V277759.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 The system for the recruitment of staff is robust to ensure that service users are protected. 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 was seen to be held on their files. Training continues to be undertaken by all staff, with four carers recently completing a course on Dementia. Four senior carers have completed training on record keeping. Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 20 The staff records did not contain evidence of recent training and the new manager is aware of this. A full review of staff files is planned to ensure that evidence of training, together with relevant certification, is held. Evidence that all qualified staff have continued to register with the Nursing and Midwifery Council is held in the home, and reminders are sent to the nurses when their registration is due for renewal. Mersey Parks DS0000025196.V277759.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 The safety records within this home are well maintained to promote the protection of service users. EVIDENCE: The home has been without an effective management structure for almost one year. A new manager has been appointed and has already made inroads into addressing many of the issues highlighted at this inspection. The manager is a qualified nurse who has considerable experience in the management of a care home for elderly people. She has been employed by BUPA for some years and is fully aware of the corporate processes as well as those required by CSCI. Evidence of her ongoing professional development was seen. An application to register the manager is currently being processed by CSCI. Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 22 Many changes have been made since the appointment of the manager and all changes have had the support of senior managers within BUPA. The home provides service users with comment cards to enable them to express their views of the home. Comments are welcomed from service users, 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.V277759.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 X X 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 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 2 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.V277759.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement The Registered Person must ensure that full assessments are undertaken on service users to identify their individual care and social needs. The Registered Person must ensure that care plans contain full information and are regularly reviewed and updated to contain all information for care staff to provide for the service users. This remains outstanding from the inspection of June 2005. The Registered Person must promote and maintain service users’ health and ensures access to health care services to meet assessed needs. The Registered Person must ensure that all staff follow the homes policy and procedure for the administration of medications. This remains outstanding from the inspection of June 2005. The Registered Person must ensure that routines of daily living and activities made DS0000025196.V277759.R01.S.doc Timescale for action 31/03/06 2. OP7 15 31/03/06 3. OP8 12(1)&(3) 09/01/06 4. OP9 13(2) 09/01/06 5. OP12 12(2)(n) 10/02/06 Mersey Parks Version 5.1 Page 25 6. OP15 16(2)(j) 7. OP30 17(2) available are flexible and varied to suit service users’ expectations, preferences and capacities. The Registered Person must ensure that meals are served in accordance with the environmental health authority. The Registered Person must ensure that records in relation to staff training is held on their files. 09/01/06 10/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mersey Parks DS0000025196.V277759.R01.S.doc Version 5.1 Page 26 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.V277759.R01.S.doc Version 5.1 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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