Inspection on 02/07/07 for Park Cottages

This inspection was carried out on 2nd July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Park Cottages 18/12/07

Park Cottages 06/07/06

Park Cottages 09/11/05

Park Cottages 20/07/05

Park Cottages 20/10/04

Park Cottages 27/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Park Cottages Neville Avenue Kendray Barnsley South Yorkshire S70 3HF Lead Inspector Mrs Sue Stephens Key Unannounced Inspection 2 and 3rd July 2007 16:00 nd Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 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 Park Cottages DS0000018268.V337770.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park Cottages Address Neville Avenue Kendray Barnsley South Yorkshire S70 3HF 01226 771891 none none None Park Care Limited 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) Carol Gibbons Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2006 Brief Description of the Service: Park Cottages is a stone built cottage adapted from a barn conversion; Park Cottages provides care and accommodation for six adults with learning disabilities. The property stands in the grounds of Park Grange Care Home, which is owned by the same proprietor. There are two levels to the home and all bedrooms are single accommodation. There is a small garden to the front and rear of the building and car parking is shared with the adjacent home. The building is not suitable for wheelchair users. The home is in the residential area of Kendray; it has good access to public services and amenities, and these include bus services, supermarket, chemist, hairdresser, post office, newsagents health centre, and local pubs. The manager provided the information about the homes fees and charges on 9th July 2006. The fees were £393.06 per week. Additional charges include hairdressing, toiletries, newspapers and magazines. Prospective residents and their families can get information about Park Cottages by contacting the manager. The home will also provide a copy of the statement of purpose and the latest inspection report. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced; it took place between 16:00 pm and 18:10 pm on 02/07/07 and between 10:00 am and 14:00 pm on 03/07/07. The inspector sought the views of people who live at the home, and spent time observing their care and support. She spoke to two members of staff. Carol Gibbons, the registered manager, assisted with the inspection. During the visit the inspector looked at the environment, and made observations on the staffs’ manner and attitude towards people. She checked samples of documents that related to peoples’ care and safety. These included three assessments and care plans, medication records, and staff recruitment files. The inspector looked at other information before visiting the home, this included evidence from the last key inspection. The manager and responsible individual did not provide the Commission for Social Care Inspection with their AQAA (annual quality assurance assessment). This is a regulation requirement that all care services must provide. The inspector gave the manager advice and guidance about how to complete these. Because the home had not provided an AQQA the Commission for Social Care Inspection did not have contact numbers to send out surveys to family, friends and professional contacts. Following the visit to Park Cottages the inspector contacted three relatives by phone to ask them their views about the home. This was a key inspection and the inspector checked all the key standards. The inspector would like to thank the people who live at the home, the manager and staff for their warm welcome, help and contribution to this inspection. What the service does well: They assess people’s needs before deciding if the home is suitable to support them. And they involve people in their assessments. The home looks at people’s diverse needs during their assessments to make sure they understand their needs. People are very happy with the support they get. They said they have good relationships with staff and feel like a “family”. They get good support to help them make decisions and choices in their lives. People said they were happy with their daily routines. They had good support to access education, occupation and leisure activities. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 6 People were very involved in meal planning. They helped to plan, shop and prepare their own meals. They said they enjoyed their meals and there was always plenty. People felt they had good personal support and staff supported them to access health care services. Relatives said they were satisfied, and said the home had a good staff team. People could complain or raise concerns and the manager and staff would listen. People liked the home’s environment. They said it was comfortable, clean, and homely. Staff were friendly and approachable. People and relatives said they thought the home had a good staff team. What has improved since the last inspection? What they could do better: Improve people’s care plans and risk assessments to help promote safe and consistent care. Make sure staff record medication information correctly. And make sure staff are safe to give people support with their medication. The home needs to replace the broken chair to avoid injury to people. The staff team need up-to-date training on safe working practices (such as fire, moving and handling and food hygiene), and on care and support practices. New staff need better information when they start work at the home, (a better induction). This will help make sure they understand their job properly and give people the right kind of support. The manager needs adult protection training (safeguarding adults) to make sure the home does the right things to keep people safe. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 7 The manager also needs to get a National Vocational Qualification in care and management (NVQ level 4) so that she can show she has the right skills to run the home well. The finance and recruitment records need to improve to show they protect people from abuse. The responsible individual (the person who provides the service) needs to visit the home, unannounced, at least once a month. And make a report on the homes progress. This will show how the responsible individual and the home makes sure it improves things for people who live there. The responsible individual and manager have to produce a report on time, called an AQAA (annual quality assurance assessment), to show how well the service is doing and what they need to do to improve. The home needs to do regular water temperature checks. This will help protect people from scalds. The home needs to do risk assessments, so that they can keep people safe in and around the home. 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. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People who live at the home have their needs assessed before they move in. This helps make sure Park Cottages is the right place for them to meet their needs and aspirations. EVIDENCE: People had assessments carried out by social and health care professionals before they considered Park Cottages as a place to live. The assessment process looked at people’s diverse needs. For example it looked at their religion, disability and age. Following this the manager and staff met the person. They carried out their own assessment with the person, and their family, to make sure they understood the person’s needs and wishes. The assessment was thorough and asked questions about what people liked and preferred. This was good practice and helped the person to start living at the home with support from staff who understood their needs. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 10 The manager carried out the assessments; she had experience in assessing people’s needs and confirmed she always involved the person in the assessment. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People were satisfied that they could make their own decisions about their lives. People did not have good care plans and risk assessments to reflected their goals, aspirations and support needs. EVIDENCE: People said they were very happy about the support they got, to make decisions in their lives. They said they had good relationships with staff who helped them with choices and difficult decisions. Relatives also said that staff were supportive and helpful. The inspector observed staff and noted they had good conversations with people, and noted that staff encouraged people to tell them what they wanted. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 12 The home had made little progress on the previous requirement to improve care plans. The manger did however have a care plan for one person, almost complete, and intended to use this as a model for other people’s care plans. If completed well, the care plan would provide the person with good information to share with staff about their support needs and what they needed staff to know to help them. The remaining care plans did not reflect people’s support needs enough. And the manager had not transferred people’s assessed needs into the plans. The manager said staff were expected to make daily records about people’s progress and events. However, on some occasions staff had missed recording information, sometimes for days at a time. This left the home without evidence of what support they had offered the person and if there were any changes in their needs. One person’s information had only one risk assessment and no plan of care. This suggested the home was confused about what a support plan and what an assessment of someone’s risk was. The inspector looked at the new model care plan and asked the manager to complete this, and one other, and bring it to the Commission for Social Care Inspection on an agreed date. This will enable the manager to demonstrate that she is making real progress to put satisfactory support plans and risk assessments in place for people. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, and 17. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People were satisfied with the support they received to carry out their daily routines, education, occupation, and leisure activities. People had good support to maintain relationships with family and friends. EVIDENCE: People said they liked their daily routines. They said they had particular days they looked forward to because it meant going out and meeting with friends, such as at a club or home to family. People said they could choose what they wanted to do in their leisure time for example listen to music, do jigsaws, spend time alone in their bedrooms and spend time with staff. People at the home and relatives said the opportunity to go out was very good. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 14 Relatives said, “They always seem to be off out somewhere” “(name) has a much better social life”. Another person said, “I like the club” and enjoyed going with friends from the home. They confirmed the home always gives them support to get there and return home safely. People at the home were very organised they chose themselves who wanted to go shopping, and shared a rota for domestic chores. Relatives and people at the home said staff were good at helping them keep in touch. Relatives said they always had a welcome at the home and staff gave people support to visit family and friends. People had access to occupation and education through day-centres and supported employment. For people who did not need full time occupation or education the home provided staff for them to spend time at home during the day. People said they enjoyed their meals. People at the home were very involved with planning, shopping, preparing and serving meals. They chose what they wanted to eat, contributed to the shopping list, and made suggestions for meals. One staff said, “they can have anything they want, they often choose things they see in the supermarket. So long as its reasonable its ok to have”. Mealtimes were a family style event. People sat around a large table in the kitchen, staff sat with them to eat meals. The event was relaxed, dignified and social. People helped themselves to a choice of foods. The food was fresh varied and nutritious. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People receive good support to maintain their personal and health care needs. However, some of the homes medication practices do not fully protect people’s safety and welfare. EVIDENCE: People said they were happy with how staff supported them with their personal and health care needs. A relative confirmed that staff shared appropriate information with them, and that they were confident staff monitored their family members health care well. People looked well presented. Their clothes were clean and the inspector noted staff gave support and advice to people to help them with their appearance. This was good practice because it promoted peoples dignity and self esteem. There was a family feel about the home, and one person who lived there, and a relative referred to care and support as being “like a family”. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 16 The home had not reflected the people’s health and personal support needs very well in their care plans. See standard 7 for information and requirements about this. The home followed safe medication practices, in the main. This included the receipt, administration, storage and records. Staff had written an instruction on one medication record that did not copy exactly what the person’s prescription said. This could lead to a medication error. The inspector brought it to the manager’s attention during the visit, and the manager agreed to correct it. The home provided staff with medication training. However, for some staff the home needed them to start administering medication before they had completed training. The manager said she assesses their competence through observation first. But did not have records to demonstrate this. This could put people at risk if the manager has not taken enough action to make sure staff are safe and understand procedures. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People can raise concerns and the home will take action. Some of the homes practices for safeguarding people are not sufficient enough to minimise the risk of abuse. EVIDENCE: People and relatives said they felt ok about raising concerns and complaints. They said they could approach the manager or staff and they would listen. The homes complaints procedure was on display in the hallway for people and visitors to see. Staff had access to a brochure that they could hand out if someone asked for information about how to complain. The manager said she had not dealt with any complaints or adult protection issues over the past year. The manager had not had training on adult protection (safeguarding adults) for over 3 years; and the training had been a basic course. This was not enough to make sure the manager had the right skills to identify and take action if someone might be at risk of abuse. This is a previous requirement and it is disappointing that the manager has not taken action. Safeguarding adult training is available to the home via Barnsley local authority training resources. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 18 The homes finance records were not sufficient to show clear withdrawal, expenditure and deposits. This included people who contributed money for transport. The home had one record rather than an individual record for each individual; this could not demonstrate people’s individual balances. The home had no evidence to show how it managed people’s benefits (received by the provider) and contributions to transport. The inspector asked the manager and responsible individual to bring improved records to the Commission for Social Care Inspection on an agreed date. This will enable the home to demonstrate that they manage people’s monies in a safe and consistent way, and that the system prevents opportunities for abuse. The manager reported that she had received no complaints or dealt with any adult protection issues since the last inspection. The Commission for Social Care Inspection had not received any complaints or adult protection referrals. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People are satisfied with the environment they live in. It is clean, comfortable and homely. EVIDENCE: People said they were happy with their environment. They confirmed they had everything they needed in their own rooms and the communal rooms suited their needs. Relatives also said they felt the home was clean and comfortable. One relative said “I think it is lovely”, “(person who lives in the home) is settled and treats it as their home, and it is clean”. Staff had helped decorate and furnish the home in a very homely manner. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 20 The manager and staff said sometimes they had to wait for some repairs a long time. The manager said she gave repair lists to the maintenance person, who also worked at the organisations other home. But, sometimes he could not do the repairs at Park Cottages as quickly as should be. A relative also commented that repairs “take a while to do”. There was a broken chair in the lounge. It had damaged seating, but you could not see this unless you sat in it. The chair was uncomfortable, and it put people at risk of injury. This did not promote people’s safety and dignity. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People who use the service experience poor quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People and their relatives said the staff team gave people good support. The home could not demonstrate complete, safe and robust recruitment practices. Staff training was out of date; this did not support staff to have safe consistent and up to date care skills. EVIDENCE: People said they liked the staff team. They said they had good support and staff were helpful and friendly. Relatives said staff were, “Really friendly, they will do anything for you” “Approachable” Fifty percent of staff had a National Vocational Qualification. This enables staff to demonstrate they understand the principles of care and support. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 22 The homes recruitment records were not in good order. The filing system was disordered and contained loose leaves of information. As a result it was difficult for the inspector to check if the manager had carried out and maintained proper recruitment procedures. The inspector spent time with the manager to explain what the National Minimum Standards and Care Home regulations required. This was because this was a previous requirement and the manager could not show any improvement in the systems. The manager and responsible individual agreed to come to the CSCI officers at later date after the inspection to show they had taken action to improve the records. For some employees the home could not demonstrate that they had got a full employment history from staff, before they started work. They need this information, before they employ staff, to help the home check that they employ suitable staff. The homes training records were not in good order or up to date. Staff had not had sufficient training over the past year. And the manager did not have a plan of necessary training, based on peoples support needs for the coming year. The inspector spent time with the manager to explain what the National Minimum Standards and Care Home regulations required. The home did have some internal training packages such as fire training. However records to demonstrate clear training dates and staff competence were not in good order. The homes induction package did not meet sector skills council standards. This meant the home could not be sure it was providing staff with safe, consistent and up to date with current practice induction. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience poor quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The management systems are not thorough enough to make sure the home is well-run and makes continual improvements. EVIDENCE: The manager has over two years experience in management. However, she had still not started National Vocational Qualification training for a management qualification. The manager would have better skills and knowledge to improve the management and administration at the home if she completed the training. The manager had not attended any training over the past year in order to develop her skills and keep up-to-date with current care practice. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 24 The home had almost no quality assurance systems in place, including the following: Record systems had made little improvement from previous inspections; this has prevented the home improving people’s safety and development. (See standards referring to care plans, recruitment and training). There was no evidence to show if the responsible individual had carried out monthly-unannounced visits to the home. The home had no reports from the responsible individual to show where he had monitored and identified areas for improvement. This does not help promote peoples, safety, rights and dignity. The responsible individual and registered manager had not complied with legislation; they did not provide the commission with AQAAs (annual quality assurance assessments). The manager confirmed that the home did have water temperature valves fitted, but did not make checks to check if they worked. This put people at risk of scalds. Staff did not have up to date training on safe working practices, this means people could be exposed to unnecessary risks. Some staff did have up-to-date training, however other staff were without the following current training, • Health and safety • Fire • Food hygiene • Moving and handling • First aid • Infection control The manager was unable to show up-to-date and reviewed risk assessments that look at the potential risks in and around the home, and how to minimise these. Park Cottages DS0000018268.V337770.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 1 X X 2 X Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15.1 Timescale for action People must have care plans that 17/08/07 that reflect their support and care needs. These must include clear instruction on the action staff must take to give a person care and support. This will help make sure people receive safe and consistent care, and help to develop their independence. The manager and responsible individual must produce two people’s completed care plans by the agreed date. (See date in timescale for action) 2 YA9 13.4(b) The manager must make sure risk assessments consider potential risks to individuals. For example in their daily routines, activities and environment. This will help make sure people Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 27 Requirement 30/09/07 are not exposed to unnecessary risks, and enable them to take reasonable risks to promote their independence. 3 YA20 13.2 When staff write medication instructions on the medication administration charts, they must put the complete instruction copied word for word. And another staff member must check the accuracy. The manager must be able to demonstrate that staff are competent before they can administer medication unsupervised. This will prevent putting people at risk of receiving medication errors. 4 YA23 13.6 The manager must attend adult protection training. This will help make sure she has the skills to take the right action, and give the home the good and safe support, if the home has to deal with an allegation of abuse. (The previous timescale for action was 31/01/06 and 30/09/06) 5 YA23 13.6 The responsible individual and manager must improve the finance records to show clear and consistent deposits and withdrawals. This must include both personal and mobility records. The manager and responsible individual must produce these to the Commission for Social Care Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 28 31/08/07 30/11/07 17/08/07 Inspection by the agreed date. (See date in timescale for action) This will help make sure the home can demonstrate it has robust systems in place to keep people safe from financial abuse. 6 YA24 23.2(g) Replace the broken lounge chair. This will prevent injury and respect people’s dignity and comfort. 7 YA34 19.1(b)(i) Schedule 2 The recruitment records must be maintained in a safe way. Information must be filed so that it is accessible. The home must obtain a full employment history from all new staff before they commence work at the home. The manager and responsible individual must produce improved records to the Commission for Social Care Inspection by the agreed date. (The previous timescale for action was 31/08/06) This will help make sure the home can demonstrate it takes positive action to make sure they employ suitable staff to give people care and support. 8 YA37 17.1(a) schedule 3 The manager must make sure the new recording systems are introduced safely, and information is kept safe during the process. (The previous timescale for action was 30/09/06) 30/09/07 17/08/07 31/08/07 Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 29 9 YA39 26.4 26.5(b) The responsible individual must 31/08/07 carry out an unannounced visit at least once a month; and make a written report on the conduct of the home. The manager must receive a copy of the report. The report must be available for the Commission for Social Care Inspection to review. This will enable people who live at the home to express their views, and enable to provider to monitor and review the homes development. 10 YA39 24.2 The responsible individual and registered manager must comply with legislation and ensure they provide the commission with AQAAs (annual quality assurance assessments). This helps the home demonstrate the standards of care and support offered to people who live there. 30/09/07 11 YA42 13.4(a) Staff must carry out water temperature checks on taps where people have access to them. This will prevent the risk of people getting scalded. 31/08/07 12 YA42 13.4(c) Staff must have up to date training on safe working practices to make sure people are not exposed to unnecessary risks. For example: • Health and safety • Fire 30/11/07 Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 30 • • • • Food hygiene Moving and handling First aid Infection control (The previous timescale for action was 30/09/06) 13 YA42 13.4(c) The responsible individual and manager must make sure the home has up to date risk assessments. These must consider potential risks in and around the home and how to minimise these. This will help make sure people are not exposed to unnecessary risks. 31/08/07 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 Refer to Standard YA6 Good Practice Recommendations Staff should make daily records of the support and events of individual people. This will help people to monitor their progress with staff and identify any changes in their support needs. The responsible individual should review the maintenance program to make sure people get a good service, and make sure repairs are completed in reasonable times. Staff should have a minimum of 3 days training per year and should have training that reflects the care and support needs of people who live at the home. New staff should have an induction that meets Skills for Care standards. The registered manager should undertake NVQ Level 4 in DS0000018268.V337770.R01.S.doc Version 5.2 Page 31 2 YA24 3 YA35 4 5 YA35 YA37 Park Cottages care and management by 2005. Recommendation carried forward from inspection dated 06/07/06. 6 YA37 The manager should look at the new recording systems and prioritise which needs to be completed first. Recommendation carried forward from inspection dated 06/07/06. 7 YA37 The manager should look at relevant training to up date and develop her skills. The manager should attend at least 3 days training per year. Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Park Cottages DS0000018268.V337770.R01.S.doc Version 5.2 Page 33 - 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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