Inspection on 06/06/08 for Molyneux Park Rest Home

This inspection was carried out on 6th June 2008.

CSCI found this care home to be providing an Adequate service.

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

Molyneux Park Rest Home 24/05/07

Molyneux Park Rest Home 09/11/06

Molyneux Park Rest Home 28/02/06

Molyneux Park Rest Home 22/11/05

Molyneux Park Rest Home 15/02/05

Molyneux Park Rest Home 27/04/04

Molyneux Park Rest Home 14/10/03

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Molyneux Park Rest Home 38 Molyneux Park Road Tunbridge Wells Kent TN4 8DY Lead Inspector Helen Martin Unannounced Inspection 6th June 2008 10:00 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 Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Molyneux Park Rest Home Address 38 Molyneux Park Road Tunbridge Wells Kent TN4 8DY 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) 01892 544322 Mr Colin Wallis Mrs Sheila Wallis Mr Colin Wallis Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2007 Brief Description of the Service: Molyneux Park Rest Home is registered to provide personal care and accommodation to sixteen older people. It is owned by Shelia and Colin Wallis. The home is located in a quiet residential area of Tunbridge Wells near to local shops. There is a nearby bus service into the centre of Tunbridge Wells; the town contains a large shopping centre and local facilities. The main line railway station is near the town centre. Accommodation at the home is on three levels with access to upper floors via stair lifts, there are ten single and three double rooms, one double room is used as a single. Communal areas consist of a lounge, dining room and conservatory. Three of the single rooms are equipped with en suite facilities. There is a staff call system and each room has a television point. A small garden and patio to the rear of the building with a lawned area are available for residents to use. The home provides care staff, working a roster, which gives 24-hour cover. Staff are also employed for catering and domestic duties. Current fees for the home range from £326.33 to £400.00 per week. Additional costs include hairdressing, toiletries, chiropody and newspapers and magazines. Full information about the fees payable, the service provided and the home’s Statement of Purpose are available from the owners. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced visit took place on 6th June 2008 and included talking with the Registered Providers, two care staff, the cook and six people who live in the home. (The Registered Provider mentioned in the text of this report is Sheila Wallis) Some judgements about the quality of life within the home were taken from observation and conversation. Some records were looked at. A tour of the premises was undertaken. The home did not return a completed Annual Quality Assurance Assessment to the CSCI and therefore this could not be used within this inspection process. Currently there are thirteen residents accommodated. Comments received from residents spoken with at the time of this visit include: individuals are happy in the home which is warm and comfortable, residents are happy with the activities provided, the food is very good and they get a choice, family members visit and take residents out, they like their room and can bring their own furniture, individuals can choose what time to get up and go to bed and the routines of the home are flexible, the staff and owners are very good and kind, they help residents with the stair lift and come straight away if they have to use the call bell, residents have no complaints. What the service does well: Individuals are given the information they need before they decide to move into Molyneux Park. Procedures are in place to ensure that the home is suitable to meet prospective residents’ needs. They enjoy living in a clean, comfortable, warm and homely environment. Residents are treated with respect. Arrangements are in place to maintain their privacy and dignity. Residents’ personal, health and social care needs are met. Individuals benefit from staff who care for, understand and anticipate their wishes. The views of residents are listened to and receive appropriate consideration. They enjoy living in a home where they are at ease speaking with staff and the Registered Providers. Residents are recognised as individuals and are able to exercise choice over their lives. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 6 Individuals enjoy their lifestyle within the home and are able to keep in contact with their family and friends if they wish. They benefit from a varied and balanced diet. The regular testing and maintenance of systems and equipment within the home protects residents’ health and safety. They are protected from potential abuse. What has improved since the last inspection? What they could do better: One owner, who is also the Registered Manager, currently works many hours in the direct care of residents in order to cover staff vacancies. As a result present staff shortages do not currently directly affect residents, although they may be put at risk by insufficient time for the management and administration of the home. Residents may be put at risk by the current number of staff employed. It is the Registered Providers’ responsibility to ensure that sufficient staff are on duty to meet residents’ needs at all times. The home does not currently maintain an accurate and up to date staffing roster. Residents are put at risk by the systems in place for staff recruitment, training and supervision. Residents’ are put at risk by the procedures for the administration of medication. The Registered Provider stated that they would obtain the latest guidelines from the Royal Pharmaceutical Society in order to follow their advice. Residents’ quality of life would be improved by the undertaking of an Annual Quality Assurance Assessment by the home. Residents are put a risk by the home not informing the CSCI of any events that adversely affect them. Care plans could better reflect that residents’ personal, health and social care needs are met. It is the Registered Providers responsibility to ensure that care plans and risk assessments are comprehensive and up to date. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are given the information they need before they decide to move into Molyneux Park. Procedures are in place to ensure that the home is suitable to meet prospective residents’ needs. EVIDENCE: Previous inspection identified that the home has a statement of purpose and service user’s guide that includes a resident’s charter; this gives written information about the home. The Registered Provider stated that the service that the home provides had not changed and therefore documentation had not altered. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 10 The Registered Provider mentioned that prospective residents and their representatives had the opportunity to look around the home before they decided to move in. Prospective residents are assessed before they move in, in order to ensure that the home is suitable to meet their needs. The local authority undertakes assessments for those residents who are funded by them; documentation was seen. The Registered Provider explained that assessments for people who are privately funded are undertaken and recorded by themselves. No written assessments for privately funded residents were looked at during this visit. The Registered Provider stated that they assess all residents before they move in. The home has a trial period for residents prior to a permanent placement to confirm that the home is suitable. When this is agreed, the Registered Provider stated that all residents are provided with a written contract detailing their terms and conditions of accommodation. The home does not provide intermediate care. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are treated with respect and their privacy and dignity are upheld. Residents’ personal, health and social care needs are met. Residents’ are put at risk by the procedures for the administration of medication. EVIDENCE: Individual plans of care for each resident are developed from assessments undertaken prior to their admission to the home. These aim to identify the support required from staff to meet residents’ personal, social and health care needs. Notes are kept of the day-to-day support provided and reviews of the information take place. Previous inspection identified that care plans should be expanded upon; whilst this has been undertaken, documentation continues not Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 12 to fully reflect all of the changing needs of residents known to staff, such as activities. Risk assessments for individual residents are included in care plans, although not all risks are recorded and documentation is in need of updating. The Registered Provider stated that all residents’ weight was monitored; although this was not recorded in the care plans seen. The nutritional needs of one individual are monitored, although not recorded in detail. It is the Registered Providers responsibility to ensure that care plans and risk assessments are comprehensive and up to date. Records seen confirmed that a range of health and social care professionals are accessed to support staff to meet residents’ needs including consultation and referral to medical professionals. One resident spoken with said that the GP and District nurse came when they needed it; the latter currently visiting on a regular basis. The home has taken appropriate action with regard to the specialist health care needs of one resident with professional advice and care being sought and recorded in the care plan; specialist equipment is currently provided. Arrangements are in place for staff to manage residents’ medication; an easily monitored system is used. Due to space restrictions medication is delivered on a weekly basis and kept in a small lockable cupboard. Administration records are completed appropriately after staff observe that residents have taken their medication. Controlled drugs have a designated storage facility, although this does not comply with current legislation and a requirement has been made. The home maintains a controlled drugs register, although this is not in line with advice from the Royal Pharmaceutical Society. Drugs taken on a ‘when required’ basis are not always clearly indicated on administration records and no written guidelines for individual residents are available. The Registered Provider stated that they would obtain the latest guidelines from the Royal Pharmaceutical Society in order to follow their advice. The owner assured the inspector that controlled drugs are now given directly from the box supplied by the pharmacy. Training is mentioned under the ‘Staffing’ section of this report. Residents are treated with respect and their right to confidentiality is upheld. Those spoken with said they were happy with their care; staff are kind, helpful and respectful. During the inspection, staff were seen to attend to residents’ needs in privacy and respond quickly when asked. Staff spoken with demonstrated a good understanding of individuals’ needs. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents are able to exercise choice over their lives. They enjoy their lifestyle within the home and are able to keep in contact with their family and friends. Residents’ benefit from a varied and balanced diet. EVIDENCE: The routines of the home are generally flexible. Residents spoken with said that they could choose when to get up and go to bed and when to spend time in their rooms or in the communal areas of the home. Residents spoken with enjoyed their lifestyle and described how they liked to spend their time; this includes monthly physical motivation, listening to a visiting singer, crosswords, colouring and watching television and DVDs. All enjoyed visits by a dog. Birthdays are celebrated with a party. All residents Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 14 spoken with stated that they were happy with the activities provided. One resident mentioned that they would like to go out more often; the Registered Provider explained that they would be providing a trip out in the home’s minibus shortly. Several residents are taken out by visiting relatives. Residents keep in contact with their relatives and friends. Visitors are welcome in the home at any reasonable hour. Some residents spoken with confirmed that they enjoyed visits from members of their family; they can be received in residents’ rooms, the communal areas of the home including the conservatory. The home also provides a small visitors room. Residents spoken with described the quality of the meals as very good. The menu is planned in advance and showed a variety of meals. Specialist diets can be catered for, such as sugar free. The cook demonstrated a good knowledge of individuals’ likes and dislikes; residents spoken with confirmed this and preferences are recorded. During this visit staff were observed to ask all residents what they would like for tea, all choices were individual. A diary is kept to record residents’ meals and choices. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of residents are listened to and receive appropriate consideration. Individuals are protected from potential abuse. EVIDENCE: At the time of this visit, residents were at ease talking with staff who listen to their views and concerns. Residents spoken with had no complaints about their care and said that both the staff and owners are very good, kind and helpful. Staff demonstrated how they managed an occasional specific occurrence appropriately. The Registered Provider confirmed that no complaints had been received, although the home has the facility to record these should this be the case. A written complaints policy and procedure is available for residents and their representatives. Procedures are in place, which aim to protect residents from potential abuse. The manager demonstrated an understanding of the protection of vulnerable adults; they have obtained the Kent and Medway procedures and ‘No Secrets’ documentation. The home provides it’s own policy, which has been previously reviewed to include specific information regarding reporting procedures. The reviewed version was not included within the available file. The Registered Provider assured the inspector that this oversight would be correctly Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 16 immediately. Training issues are mentioned under the ‘Staffing’ section of this report. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy living in a clean, comfortable, warm and homely environment. EVIDENCE: The home is clean and well maintained. Residents spoken with said that the home was warm and comfortable. There is a small garden and lawn area that residents are able to access. Communal facilities are well decorated and homely and include a dining room, lounge and conservatory area. The owner said that since the last inspection, a new carpet has been fitted in the lounge as have new cupboards in the kitchen and one bedroom has been redecorated. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 18 As the property is a converted older style house, bedrooms vary in size and shape. All bedrooms seen are attractively decorated and personalised by residents. Those spoken with stated that they liked their room and some were able to bring personal items of furniture with them when they moved in. All current residents are accommodated singly with the exception of two. Previous inspection identified that although the occupants had been offered single rooms, they wanted to continue to share. The Registered Provider confirmed that the shared room continued to be occupied by the same residents. There are enough bathrooms and toilets throughout the building. Three bedrooms have ensuite facilities, one contains a shower cubicle and one has a designated bathroom. There are two communal bathrooms one on the ground and one on the first floor. Rooms on the top floor all have individual facilities. Bedrooms are located on the ground, first and second floors; stair lifts provide access to each floor. Residents spoken with described how staff assist them with the stair lifts and bath hoists when necessary. Residents mentioned that staff come straight away if they have to use the call bell. Specialist equipment is currently provided for one resident. All the radiators seen were guarded. It is the Registered Providers’ responsibility to ensure that any exposed hot water pipes are risk assessed in order to prevent the risk to residents of scalding. Hot water temperatures are tested regularly; one outlet checked during this visit was an appropriate temperature to the touch. All the areas of the home seen are clean and tidy. The Registered Provider explained that they are in the process of addressing a slight odour in one bedroom and one bathroom, and that this would be resolved shortly. It was stated that procedures are in place for the use of the bedpan washer in one communal bathroom. The basement of the home includes a small laundry area, the kitchen and food storage cupboard. The Registered Provider stated that since the last inspection, the home had received a Gold Good Hygiene award from the local council. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from staff who understand and anticipate their wishes and needs. Residents may be put at risk by the current number of staff employed. Residents are put at risk by the systems in place for staff recruitment and training. EVIDENCE: Residents speak very highly of the care provided and how approachable the staff and Registered Providers are; this was confirmed by observation of good interaction at the time of this visit. Some staff have been at the home in excess of twenty years, are very committed to their roles and knowledgeable about residents’ needs. Staff observed are confident and competent and manage all their required tasks without compromising the needs of residents. One resident stated ‘I don’t have to worry about anything…it’s all done for me’. There were enough staff on duty to meet residents’ care needs at the time of this visit and staff spoken with confirmed this. The Registered Provider said Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 20 that staff vacancies had arisen during the last couple of months due to unforeseen circumstances. The home employs a cook during the week with one owner providing meals at the weekends. The Registered Provider currently works many hours in the direct care of residents and existing care staff work additional hours to cover the vacancies. As a result of this staff shortages do not currently directly affect residents, although time for the management and administration of the home is compromised. In addition there is little back up in case of illness or holidays. Staff spoken with confirmed that they had appropriate time off per week. The Registered Provider stated that should the staff vacancies not be covered by existing arrangements, they would employ agency staff. It was said that the home is currently in the process of recruitment. It is the Registered Providers’ responsibility to ensure that sufficient staff are on duty to meet residents’ needs at all times. It was not possible to fully evidence whether residents’ needs are met by enough staff on duty at other times, as the staffing roster was not available. It was explained to the Inspector that this had not been updated recently. The maintenance of an accurate and up to date staffing roster is a legal responsibility and a requirement has been made. This includes the necessity for the Registered Providers to supply staffing rosters for April, May and June 2008 to the CSCI. It was mentioned that since the last inspection, three new staff had been employed. The recruitment procedure in place within the home aims to ensure that suitable staff are appointed to meet the needs of residents. The Registered Provider described appropriate pre-employment checks. Documents for two new members of staff were looked at; the necessary documents were present with the exception of proof of identity and one criminal records bureau disclosure. It was not possible to fully evidence whether residents were protected by recruitment procedures, as insufficient records were available for inspection. The Registered Provider assured the inspector that they would confirm and record employment checks for one NVQ assessor used by the home. Discussion took place regarding the appropriate level of supervision for one member of staff. On the day of inspection, one criminal records disclosure was not available. However during a subsequent telephone conversation, the Registered Provider assured the inspector that the disclosure had been found, returned but misfiled, and therefore an appropriate level of supervision was currently in place. Staff spoken with mentioned that there is a good rapport with the owners and that they are always available. It is evident that the staff group works as a team and supports each other; there is ample opportunity during the working day to consult the Registered Providers or each other about any problems or concerns. As the home is run as a family unit the supervision of staff is Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 21 currently on a less formal basis. Recorded formal supervision is currently not provided for staff in line with Schedule 4 6(f), a requirement has been made. The Registered Provider explained that after appointment, all new staff are provided with induction training. The Registered Provider was unclear as to whether this complied with Skills for Care. No staff induction records were available for inspection. The Registered Provider indicated that there continue to be difficulties in accessing external training to keep staff current in their knowledge and skills. The Registered Provider has acquired DVD training aids that can be delivered in house and reinforced with competence-based tests by an external NVQ assessor to ensure the understanding of individual staff. It was stated that inhouse training for fire prevention and continence had recently been undertaken and staff spoken with confirmed this; adult protection, medication, food hygiene, infection control and first aid would be arranged shortly. The Registered Provider said that all in-house training was a refresher course as all staff had undertaken the necessary external training previously. No training certificates were available for inspection, except for one staff member; these showed that although some training had been undertaken, the majority was in need of updating. A training matrix has not been developed by the home. It was not possible to fully evidence whether residents’ needs were met by adequate and up to date staff training, as insufficient records were available for inspection. Currently over 50 of the care staff either have obtained or are in the process of NVQ 2. Although only one member of staff has an NVQ level 2 qualification, a further three have enrolled for the course; staff spoken with confirmed this. An external NVQ assessor visited the home on the day of inspection. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents enjoy living in a home where they are at ease speaking with staff and the Registered Providers. Residents may be put at risk by lack of up to date, accurate and accessible records of the home. Residents’ quality of life would be improved by the undertaking of an Annual Quality Assurance Assessment by the home. Residents are not protected by the systems in place for staff supervision. Residents are put a risk by the home not informing the CSCI of any events that adversely affect them. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Registered Providers are knowledgeable about the needs of older people who require residential care. They have many years of experience of running a care home and are usually present on a daily basis. One Registered Provider currently works many hours in the direct care of residents in order to cover staff vacancies. As a result staff shortages do not currently directly affect residents, although time for the management and administration of the home is compromised and legally required documents not completed or inaccessible. The atmosphere is open and friendly and very much that of a family run service. Observations during this visit demonstrated a mutual respect between staff and residents. Individuals are at ease speaking with staff and the Registered Providers and it is evident that discussions take place on a regular basis, although these are not formalised or minuted. The Registered Provider described the home’s quality assurance system. It was mentioned that surveys were due to be sent to residents, their relatives and/or representatives and health and social care professionals shortly. Surveys are also left in the hallway for people to complete if they wish. The home did not return a completed Annual Quality Assurance Assessment (AQAA) to the CSCI and therefore this could not be used within this inspection process. This is a legal responsibility and a requirement has been made to return a completed AQAA to the CSCI by 20/06/08. Issues regarding staff supervision have been mentioned previously under the ‘Staffing’ section of this report. Residents all manage their own finances or receive support from relatives, solicitors or representatives. Lockable facilities are provided. The Registered Provider stated that the home does not hold any cash on behalf of residents nor were they an appointee for any individual. The home provides a range of written policies and procedures, a sample of which have been looked at; some have been mentioned previously in this report. These are located in a communal area and are accessible to both staff and residents. The owner said that all policies and procedures were reviewed in 2007. Records of accidents and incidents are recorded appropriately. It was noted that one fall and two hospital admissions had not been reported to the CSCI. It is the Registered Providers’ responsibility to report to the CSCI without delay, any event which adversely affects the well-being or safety of any resident and a requirement has been made. Other records looked at as part of this visit have been mentioned within this report where appropriate. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 24 A sample of documents and certificates seen at the time of this visit generally indicated the regular testing and maintenance of systems and equipment within the home. The Registered Provider sated that the regular checks undertaken for the staff call system would be recorded in future. Environmental risk assessments are undertaken. The Registered Provider said that the home’s fire risk assessment, recently reviewed verbally with no change would be confirmed in writing. The opening of windows is restricted in order to reduce risks to residents. Storage for food and cleaning chemicals is appropriate. Health information for hazardous chemicals is available. Fridge, freezer and hot food temperatures are tested and recorded daily. The Registered Providers stated that since the last inspection, the home had received a Gold Good Hygiene award from the local council. Issues regarding staff training have been mentioned previously within this report. Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 2 2 Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 26 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. 1 Standard OP9 Regulation 13(2) Timescale for action The registered person shall make 06/09/08 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. In that, controlled drugs must be kept in a designated storage facility that complies with current legislation. 2 OP27 OP37 17(2) Sch 4:7 A copy of the duty roster of people working at the care home, and a record of whether the roster was actually worked must be kept in the care home. In that, an up to date and accurate duty roster must be maintained and kept in the home, in order to evidence that residents’ needs can be met by sufficient staff on duty at all times. 3 OP27 OP37 Molyneux Park Rest Home Requirement 20/06/08 17(2) Sch 4:7 Copies of staffing rosters for July, August, September 2008 must be supplied to CSCI by 15th August 2008 DS0000023987.V363296.R01.S.doc 15/08/08 Version 5.2 Page 27 4 OP29 OP37 19(1)(b) Sch 2 The registered person shall not employ a person to work at the care home unless they have obtained in respect of that person the information and documents specified in Schedule 2. In that, comprehensive recruitment documentation must be maintained and kept in the home (including criminal records bureau disclosures and proof of identity) in order to fully evidence that residents are protected by the recruitment procedures of the home. 20/06/08 5 OP30 OP37 18(1)(c) (i) The registered person shall ensure that people employed to work at the care home receive training appropriate to the work they are to perform (including structured induction training) In that, staff induction and ongoing training must be reviewed to confirm that all staff are provided with appropriate updated courses that meet the needs of residents. Comprehensive staff induction and ongoing training records must be maintained and kept in the home, in order to fully evidence that residents’ needs are met. A copy of the staff training matrix must be supplied to the CSCI by 06/08/08. 06/08/08 6 OP33 24(2) The registered person shall, at 20/07/08 the request of the CSCI, supply a report; which includes, good quality services, the views of DS0000023987.V363296.R01.S.doc Version 5.2 Page 28 Molyneux Park Rest Home residents, a response to any requirements or recommendations and any improvements necessary; within one month of receipt by the care home. In that, on request by the CSCI, the home must return a completed Annual Quality Assurance Assessment within the timescale specified by the CSCI. A completed Annual Quality Assurance Assessment must be returned to the CSCI by 20/07/08. 7 OP36 OP37 18(2)(a) Schedule 4 6(f) The registered person shall ensure that persons working at the care home are appropriately supervised. In that, comprehensive formal staff supervision must be undertaken and records maintained and kept in the home, in order to fully evidence that residents’ needs are met. 8 OP38 37(1)(d) The registered person shall give notice to the CSCI without delay of any event in the care home which adversely affects the wellbeing or safety of any resident. In that, the CSCI must be notified without delay of all incidents and/or accidents that adversely affect residents’ well being. 07/06/08 06/08/08 Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 29 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 Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Molyneux Park Rest Home DS0000023987.V363296.R01.S.doc Version 5.2 Page 31 - 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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