Inspection on 09/11/05 for Park Cottages

This inspection was carried out on 9th November 2005.

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 02/07/07

Park Cottages 06/07/06

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 Unannounced Inspection 9th November 2005 08:00 Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 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.V261459.R01.S.doc Version 5.0 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.V261459.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Park Cottages Address Neville Avenue Kendray Barnsley South Yorkshire S70 3HF 01226 771891 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) Park Care Limited Carol Gibbons Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2005 Brief Description of the Service: Park Cottages is an adapted stone built cottage/barn conversion and 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 proprietors. The home is in the residential area of Kendray with good access to public services and amenities, including bus services, supermarket, chemist, hairdresser, post office, newsagents, health centre and local pubs. The home has two levels and all rooms are single. There is a small garden to the front and rear of the building. Car parking is shared with the adjacent home. The building is not suitable for wheelchair users. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over five hours between 08.00 and 13.20 hrs, and the lead inspector Mrs. Sue Stephens was accompanied by Mrs. Christine Rolt, Regulation Inspector. The inspectors observed the residents’ daily routines and interactions between the residents and staff, inspected the premises, chatted with five residents, interviewed the member of staff on duty and discussed various aspects of the running of the home including administration and records with the manager. The residents, staff and manager are thanked for the welcome they gave to the inspectors and their assistance during this inspection. What the service does well: Residents said that they enjoyed their occupational and leisure activities and were very involved in the day-to-day running of the home. At the time of this inspection, the residents and staff had recently held a Halloween Party and were planning a birthday celebration for one of the residents. The residents were offered a healthy diet and their food preferences were respected. They received good personal care and health care, and they were supported to take medication safely. The residents were treated with respect and the manager promoted this amongst staff and residents. The environment was homely and comfortable and furnished in a domestic manner. Residents were happy with their rooms, which were personalised to the residents’ preferences. There were sufficient staff provided and this included an escort to support residents to and from day centres. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The provider needs to respond to previous requirements. The statement of purpose and service user guide needs to contain better information, including fees that are charged for transport and escort. The information in the assessments and care plans need to be improved. The complaints procedure on display needs to be updated. The manager needs to for gain NVQ Level 4 in care and management and receive adult protection training. The armchair in the lounge needs to be replaced. Staff training needs to be specific to the needs of the residents. Staff supervisions need to be recorded. All staff need to carry out fire drills. Residents need to be better informed about receipt of their benefits and what the fees include. This information needs to be held at the home. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 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. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 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.V261459.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 Information about the home and the home’s assessments needs to be improved; however residents’ needs were being met. EVIDENCE: The manager was still in the process of reviewing the statement of purpose and service user guide. The contract had not been updated to include charges for fees including transport and escort costs. Pre-admission assessments had been carried out. The home’s own assessment contained insufficient information. The manager was offered advice relating to this. Residents were consulted and observed during their morning routines; residents said that they were satisfied with their care. The home had also received a thank-you card from a relative acknowledging the good care given to their family member. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, and 10 Care plans need to be improved. Residents were encouraged to be involved in the running of the home and confidentiality was respected. EVIDENCE: Care plans contained basic information. The information was not provided in a format suitable for residents to understand and was not maintained in an orderly manner. The manager acknowledged this and said she was in the process of improving the plans. Residents were observed to be involved in day-to-day decision making, e.g., discussing and choosing evening events, planning celebrations, and agreeing changes to the home. Staff were seen to be positive and encouraged residents to make decisions and participate in the running of the home. Risks to residents had been carefully considered and risk assessments were in place. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 11 The staff member consulted had a good approach to maintaining a resident’s confidentiality. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Opportunities for personal development, involvement in the local community, and leisure activities were well provided. Links with family and friends were supported. Residents’ food preferences were respected and a healthy diet was provided. EVIDENCE: Residents consulted confirmed that they had good opportunities for education and community links through the day centres and colleges they attended. Residents discussed their leisure and hobby activities, these were varied to include clubs, shopping, dining out, parties and outings. The manager and the staff member consulted showed a respectful attitude towards encouraging and supporting residents with their families and friends, e.g. awareness of friendship dynamics within the home, providing information to families with the residents’ permissions and inviting families and friends to celebrations within the home. Residents discussed how they had enjoyed the recent Halloween party and were planning a birthday party. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 13 They said they were Residents said they were satisfied with their meals. involved in shopping and choosing of meals. A menu was provided, however, residents personal preferences were respected. Snacks were available and fresh fruit was on display for residents to help themselves. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Residents’ personal and health care needs were met and medication was administered safely. EVIDENCE: Residents said that they were happy with the personal support they received. The staff and manager showed a good understanding of residents’ individual needs and examples of this were observed and heard throughout the inspection. Support was given to residents needing health care, e.g. visiting GPs, specialist consultants and chiropodists. The care plans did not reflect sufficiently health care needs. Medication was administered appropriately including good record keeping. Records included a list of medication, the reasons for it being prescribed and associated side effects; residents’ consent and sample signatures of staff administering medication. In-depth training undertaken by staff supported this. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents were confident in expressing their views, however the complaints procedure needed updating and made available. The manager needs to be fully trained in identifying and dealing with allegations of abuse to safeguard residents’ wellbeing. EVIDENCE: An updated complaints procedure had been prepared for the Statement of Purpose and Service User Guide. The complaints brochures were not available and the procedure on display did not contain the correct information for the CSCI or how to contact the home’s organisation. Residents who were consulted said that they knew how to raise a complaint if needed. Most of the staff had received adult protection training and those that had not had been nominated for future courses. The manager had not received sufficient training and was advised to attend a course as a matter of urgency. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Residents lived in a homely environment that suited their needs. EVIDENCE: Residents said that they were happy with the home environment and were involved with decisions on décor. The home in general was clean and warm and regular maintenance had been carried out. The lounge was in the process of being redecorated and the kitchen was bright and clean and accessible to the residents. One easy chair in the lounge was worn and broken. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 There was an effective staff team with sufficient numbers to meet residents’ needs and recruitment practices were sufficient to safeguard residents. Specific training and recorded supervision sessions need to be implemented to ensure that residents continue to be well supported. EVIDENCE: Over 50 of the staff had attained NVQ Level II in care. Training had taken place for staff this included medication, adult protection and health & safety, however, training specific to residents’ needs, e.g. person centred planning and Learning Disability Award Framework (LDAF) had not been actioned. The manager and a member of staff confirmed that the team worked effectively together with sufficient staffing levels. Residents said that they were happy with all members of staff. Recruitment files were not checked during this inspection. However, the manager described in detail the recruitment process including documents used and the checks carried out. The manager described the support and supervision provided to staff on a oneto-one basis, however formal supervision records had not been implemented. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 and 43 Residents benefited from a well run home. The provider needs to consult with residents and staff to ensure that their views underpin the aims of the home. Fire drills need to be improved to ensure that all staff are fully conversant with the procedures. EVIDENCE: The manager had more than two years experience, demonstrated good leadership skills and was in the process of improving administration systems used within the home e.g. residents and staff records. She encouraged and motivated staff to take on initiatives to enhance residents’ lifestyles e.g. planning events and outings. The manager did not have NVQ Level 4 in Management and Care. The manager had made good progress on meeting previous requirements, but some outstanding requirements were outside the manager’s remit and have been carried forward. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 19 The manager said that the registered provider had visited the home regularly, however visits were not made in compliance with Care Home Regulations including reports submitted to the CSCI. Some fire procedures were checked and regular fire drills had not been carried out by staff who were left in charge. The manager confirmed that a rolling programme of safe working practice training was provided for all staff. The manager confirmed that the provider had not supplied details of travel and escort fees as previously required. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 3 x 2 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Park Cottages Score 3 2 3 X Standard No 37 38 39 40 41 42 43 Score 2 3 2 X X 2 2 DS0000018268.V261459.R01.S.doc Version 5.0 Page 21 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 YA1 Regulation 4 and 5 Timescale for action A statement of purpose must be 31/01/06 provided to include all information listed in Schedule 1 (Previous requirement action dates 15.12.04 and 31.8.05) The home’s own assessment tool 31/01/06 must include all the areas as outlined in Standard 2 of the NMS. A service user guide must be 31/01/06 provided for all current and prospective residents. (Previous requirement action dates 15.12.04 and 31.8.05) The statement of purpose and statement of terms and conditions must include the fees that are charged for transport and escort. (Previous requirement action date 31.8.05) The care plan must be improved 31/01/06 to include accessible information and developed in a format that residents can understand. Health care needs and their 31/01/06 outcomes must be recorded in the care plans. A complaints brochure must be 31/01/06 DS0000018268.V261459.R01.S.doc Version 5.0 Page 22 Requirement 2 YA2 14 3 YA5 4 and 5 4 YA6 15 5 6 YA19 YA22 13 22 Park Cottages made available. The complaints procedure on display must be updated to include the contact details of the provider and CSCI. The manager must receive adult protection training. The identified armchair must be replaced with new and be suitable to residents’ needs. Staff must be provided with training designed to meet the residents’ needs. (Previous requirement action dates 11.1.05 and 30.9.05) Staff must have at least six recorded supervision meetings per year. (Previous requirement action dates 11.1.05 and 31.8.05) The provider must carry out and record visits to the home and must be in compliance with Care Home Regulations. 7 8 9 YA23 YA24 YA32 13 16 18 31/01/06 31/01/06 31/01/06 10 YA36 18 31/01/06 11 YA39 26 31/01/06 12 YA42 13 and 23 13 YA43 17 Copies of the reports must be sent to CSCI Sheffield Office. Each member of staff must carry 31/12/05 out fire drills within a 12-month period and these must be recorded. Records and accounts must be 31/01/06 available at the home relating to the receipt of mobility monies and the travel and escort fees. (Previous requirement action date 31.8.05) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 23 No. 1 Refer to Standard YA37 Good Practice Recommendations The registered manager should undertake NVQ Level 4 in care and management by 2005. Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Park Cottages DS0000018268.V261459.R01.S.doc Version 5.0 Page 25 - 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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