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Inspection on 27/06/05 for Park Farm Lodge Care Home

Also see our care home review for Park Farm Lodge Care Home for more information

This inspection was carried out on 27th June 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There was very good interaction between staff and residents, and all residents spoken to (those who able to comment) were very happy with their stay in the home and complimentary about the kind and caring staff.

What has improved since the last inspection?

The kitchen was inspected and found to be very clean and orderly. Records relating to food hygiene and HACCP were seen and in excellent order. A credit to the cook. There was also seen comprehensive information for kitchen staff, which included advice on diabetic diets (insulin and non- insulin dependant residents, High fibre control and managing dysphagia (difficulty or discomfort with swallowing). Menus were seen and followed as much as possible, alternative meals were available and the kitchen staff demonstrated a good sound knowledge of individual residents likes and dislike. Menus were circulated daily to all residents that included the alternatives available and what size portion was required.

What the care home could do better:

Qualified nurses and care assistants generally provide a good standard of care. However, one of the care plans examined on the EMI unit did not indicate that a resident`s needs had been assessed properly or were being fully met. The documentation seen was poor and a record of an accident had not been recorded. These aspects were established by direct observation and following discussions with a visitor and senior staff. All accidents and incident must be reported, documented and acted upon. Relatives must be informed of any changes in physical/mental deterioration. Private paying residents were not provided with a contract of their terms and conditions of residency in the home. This has been brought to the attention of the company before and now needs to be addressed. Medication administration needs to be improved on the EMI unit and some bedroom carpets need replacing due to offensive odours. Resident`s areas must not be used as storage spaces and health and safety issues identified in this report need to be addressed.

CARE HOMES FOR OLDER PEOPLE Park Farm Lodge Care Home Park Farm Road Tamworth Staffordshire B77 1DX Lead Inspector Sue Mullin Additional inspector Mr P Dawson Unannounced 27 June 2005 10:00 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 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. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Park Farm Lodge Care Home Address Park Farm Road Tamworth Staffordshire B77 1DX 01827 280533 01827 288544 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Four Seasons Health Care Mrs Laura Ann McCormick CRH 80 Category(ies) of DE(E) 40 registration, with number OP 40 of places PD(E) 40 Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) 40 Dementia (DE) minimum age 60 years on admission. Date of last inspection 25 January 2005 Brief Description of the Service: This is a purpose built care home with nursing which can accommodate 80 service users in the above categories. The home is situated on the outskirts of Tamworth and there is a bus stop outside the main entrance, facilitating easy access for visitors.Local towns are accessible by car or public transport.There are two levels, which can be accessed by lifts or stairs. There are wide corridors with grab rails fitted throughout the building. The gardens are accessible by wheelchairs and are well maintained, appropriate seating facilities are provided.There is adequate communal space for service users and all bedrooms are single occupancy with en suite facilities, they are in excess of 10 sq. m of useable space required. Bathrooms and toilets are appropriately situated and bathroom and toilet doors are painted in alternative colours, which assists service users in locating them.The interior of the property is well maintained; clean and the décor is set to a good standard.Communal areas are spacious and comfortable.Small, quieter sitting areas are available on both floorsAdequate parking is available to the front and side of the property. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory unannounced inspection was made by two inspectors on the 27th June 2005 at 10.00 am. The inspection was undertaken using the National Minimum Standards for Older People as a reference. The total time spent for the inspection, including pre and fieldwork, amounted to 15 hours. The registered care manager, who is a first level nurse (RMN), was not on duty on the day of the inspection. There were four registered nurses and 12 care assistants on duty on the early shift. Ancillary staff on duty included; cook and 2 catering assistants, 4 domestic staff, laundry worker, 1 maintenance/ gardener, and a full time administrator. These staffing levels were adequate to meet the needs of current 70 residents in the home. The total of 70 residents included; EMI unit 32 receiving nursing care and 5 people receiving personal care. On the general unit there were 30 residents receiving nursing care and 3 receiving personal care only. There were 10 vacancies. The inspection included the following elements; a tour of the building, inspection of records relating to provision of care, discussions with several residents and relatives and also staff members. Other services provided such, as catering and laundry were determined, along with managerial aspects such as staffing and health & safety. It was evident that generally aspects of care had been addressed well, with residents able to choose the home following an assessment and invitation to visit the home. Residents care plans had been well written and included community care plans completed by social workers, where SS were funding their care. Health, personal and social care needs had generally been met and documented. Privacy, dignity and choice aspects for residents were maintained and encouraged throughout the home. The home was well maintained, and provided a safe environment for the registered client groups. A homely atmosphere had been created, and the establishment was clean warm and tidy. Some bedrooms were malodorous and this is currently being actioned by the company. Adequate areas for residents were provided and health and safety aspects had been well addressed. Staffing levels had been adequate to meet the assessed needs of the existing residents, however more Registered mental nurses should be available on the EMI unit during the night shifts. Recruitment and retention of staff aspects were good. Mandatory staff training was well organised, with induction Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 6 programmes maintained. Care staff were then being encouraged to undertake NVQ training. What the service does well: What has improved since the last inspection? What they could do better: Qualified nurses and care assistants generally provide a good standard of care. However, one of the care plans examined on the EMI unit did not indicate that a resident’s needs had been assessed properly or were being fully met. The documentation seen was poor and a record of an accident had not been recorded. These aspects were established by direct observation and following discussions with a visitor and senior staff. All accidents and incident must be reported, documented and acted upon. Relatives must be informed of any changes in physical/mental deterioration. Private paying residents were not provided with a contract of their terms and conditions of residency in the home. This has been brought to the attention of the company before and now needs to be addressed. Medication administration needs to be improved on the EMI unit and some bedroom carpets need replacing due to offensive odours. Resident’s areas must not be used as storage spaces and health and safety issues identified in this report need to be addressed. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 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 Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3,4,5 Information was available for prospective residents/relatives and significant others to make an informed choice about staying in the home. Individual health, personal and social cares needs had been established prior to admission and these identified needs were being met by experienced and caring staff. Private paying residents were not provided with a contract of their terms and conditions of residency in the home. EVIDENCE: EMI Two new residents had been admitted to the home since the last inspection, they had received appropriate introductions prior to admission both being admitted from other Care Homes. One had made weekly visits to Park Farm Lodge prior to admission. There was evidence of new residents and their families receiving adequate information about the home, visiting prior to admission and being able to make informed decisions about admission. Records relating to new residents were inspected. There were Care Management assessments for both. They had been assessed by staff from Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 10 Park Farm Lodge in their previous setting and good admission assessments were in place also. Private paying residents were not provided with a contract of their terms and conditions of residency in the home. This has been brought to the attention of the company before and now needs to be addressed. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Residents could not expect that all incidents/accidents occurring to them were reported properly to senior staff, with appropriate methods of follow up care provided. Although there was a robust policy and procedure in place for the receipt, storage, administration and disposal of medicines, not all residents could expect their medication to be administered in line with NMC requirements. Residents could expect to be treated with respect with their privacy and dignity maintained. EVIDENCE: EMI Care plans of recently admitted and other residents were sampled and care plans reflected assessed needs. Care plans were quite comprehensive and covered all relevant areas of need. The only exception in two of the sample was that little or no information was available in relation to social history, which is important for this resident group. It appeared that there were Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 12 contrasting good social histories in other inspected residents records in the home. There was good recording of personal care needs and nursing interventions. Six people required total care due to their advances stages of dementia. Three were seen to be bedfast. Five required tissue viability care relating to pressure areas. One bedfast resident has grade 4 pressure area, another grade 3; three other residents had pressure area sores mainly on their heel and were grade 2. Tissue viability specialists have been involved with the first two residents and according to staff no longer visit, as they are satisfied with the treatment being given. Appropriate alternating pressure relieving mattresses were in place. Several residents are seen to wander in the home and allowed to do so where possible, where risk is involved close supervision is exercised in one of the main lounge areas. A resident admitted 3 weeks ago has challenging behaviours and been referred to specialist CPN’s from Cherry Orchard, they visited on the day of inspection. Another new resident was noted to have some problematic behaviours, which may present some difficulty in relation to other residents and was being closely observed. These matters were adequately documented. Dealing with this type of need requires particular skill and experience. Staff have not received training in the management of violence and aggression and this should be provided by the home. A visiting relative was seen and it was clear that since her last visit 2 days previously her mother had a bruise to her head, dressing to her leg and small bruise on other leg which were not present on her last visit. She had not been told the reasons for these apparent injuries, changes in condition. Records were inspected and did not record the bruise to the head. There was doubt about the cause and whether it was even known. It is important that all accidents or marks/bruises on residents are recorded and that relatives are advised of their presence and the reasons (known or unknown) for them. This resident was seen to be transported in a wheelchair without footrests. There had been a staff handover at 8 a.m. on the day of the inspection but the marks/injuries had not been recorded or apparently discussed. The home should review the arrangements for staff handover and the recording of information exchange. Some residents required monitoring of food and fluid intake and plans were in place to record and monitor this. All residents are weighed monthly or weekly if there are concerns about weight. There was confusion about the regularity of night checks; it appeared to be 2 hourly but staff also said that bed guards were checked hourly. There are 4 staff on duty at night time which is adequate, and all residents are checked at Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 13 least 2 hourly and more frequently if required and a record made at times of check or at least summary of night care interventions for each resident. Medication is MDS (blister packs) and was inspected with MAR sheets. There were some gaps on MAR sheets where medication had been given. Care must be taken to record medication given at the point of administration. It was noted that eye drops and creams were not all dated when opened. All injuries/accidents must be recorded. The home must immediately investigate the circumstances surrounding the head injury of resident identified. Relatives must always be told of any changes relating to the health or welfare of residents. General unit Care plans were very comprehensive and included detailed social assessments, all entries were legible, signed and dated. Long and short term problems had been identified, care implemented and evaluations undertaken monthly. Nutritional/pressure area/falls/manual handling and continence were all in place. Primary nurses allocated to each resident, and regular reviews held. Several residents spoken to good not speak highly enough of the care staff. Residents looked well cared for in clothes of their own choice- some ladies with jewellery and make up on and gentlemen in ties. A very relaxed but busy environment a lot of attention was given, to maintain high standards of personal hygiene and oral care. 5 residents were nursed in bed and staff kept accurate records of turns/fluid/dietary intake. Residents also had the benefit of 24 hour care charts, which included all significant daily information. The records kept in the nurse’s office were all kept in separate easily identifiable files witch included comprehensive tracking of wound care. A nurse/manager’s report was completed for each shift, recording any significant events that are communicated down to the oncoming shift. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Residents could exercise choice and influence decisions affecting their lifestyles. Contact with relatives and friends of residents is encouraged. The home served balanced nutritious meals formulated with resident consultation and choice. EVIDENCE: EMI There is a range of activities in the home provided, arranged and lead by the Activities Coordinator. She has an imaginative approach and individual activities were seen on a 1:1 basis particularly with residents with advancing stages of dementia. Recently some residents had been taken to the local shops. It was reported that some are taken downstairs to the garden area; this is particularly therapeutic for those with a will to wander. The day of this inspection was a very hot day and none of the residents were able to access the safe garden area due to pressure of work/care needs of residents. This was unfortunate but is hampered by the unit being on the first floor and there are significant implications for staff in taking individual residents to the ground floor and supervise in the garden area. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 15 There is an open visiting policy confirmed by visiting relative who expressed satisfaction with the care provided for her mother. Meals are provided from the ground floor kitchen area to the first floor via the lift and served by care staff from the kitchenette. The dining areas are fairly spacious, although one has an area with little natural light. The areas prior to the meal looked stark with no crockery, cutlery, linen and some residents were sitting half an hour before commencing the meal, a necessity in the logistics of sitting 40 people down for a meal. Residents could forget why there are at the table. It was noted that there was ultimately no pressure upon residents to vacate the dining room, several were still eating or sitting comfortably long after the meal had been served. The nurse on duty said that staggered mealtimes were not possible on this unit. However, it was thought that more consideration should be given to this even if ultimately rejected. All stocks and supplies were stored adequately (with the exception of frozen chips in the fridge) and were plentiful. Fridge/freezer temperatures were recorded and all within normal limits. COSSH data sheets were available in a kitchen storeroom. However, two foot operated waste bins that were being used, were broken and the lid of one was permanently wedged open. A new freezer is recommended so that storing the frozen chips in a fridge is stopped. Fly screens that are flush with the windows and external door must be fitted in line with environmental health regulations. The screens on the windows were torn in places and the external door was not protected. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 Complaints or grumbles are listened to and resolved. The home policies, procedures are robust and include reference to ensure resident’s legal rights are maintained and any forms of abuse are reported immediately to the management. EVIDENCE: There is a complaints procedure in the reception area of the home, which meets the requirements of Regulation 22 and following discussions with staff, residents/relatives, evidenced that complaints and grumbles were listened to and dealt with in the correct manner. Since the last inspection one complaint has been made via this commission. This is currently under investigation. Staff on the general unit confirmed that residents are protected from all forms of abuse. Abuse issues had been discussed at length during staff induction, training and on-going supervision. POVA training has been undertaken for the majority of staff in the home during the last 12 months. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,24,25,26 The home generally provides a safe environment for all residents. The General unit was clean warm and well kept. Residents on the EMI unit were assessed individually and good observation by staff maintained. Some areas of this unit were found to be malodorous. EVIDENCE: There is a good standard of environment. The home was purpose built 8 years ago. All rooms are for single use and all have en-suite facilities. The home is generally bright and spacious with wide corridor areas appropriate hand/grab rails in corridor areas, toileting areas and communal areas. There is maintenance book for action by the maintenance person. Staff record any environmental requirements. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 18 There are 5 small lounge areas on Moorcroft (EMI), which are bright, comfortable and pleasant. It appeared that two were little used. One lounge is designated to monitor residents who are particularly highly dependent. Bathing/toileting facilities are suitable with 2 bathrooms and 2 shower rooms (all with toilets) on the unit. It was noted that the small opening door to a walk-in shower was broken and unsafe; it should be repaired/replaced in the interests of safety. Bedrooms were well furnished and mainly well personalised reflecting the individuality of residents. There were many photographs and personal items, which are particularly important for this resident group. There were malodours in 3 bedrooms relating to the continence care of residents. These were also identified on the last inspection. In the bedroom of a bedfast resident a large specialist chair obstructed access to the en-suite area. This was apparently not used by this resident. General unit The hallway carpet is worn and getting threadbare and this needs to be replaced. One area of the unit had a nurse call system failure and this was being repaired on the day of the inspection. The handyman, on a frequent basis undertook bed rail safety checks. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The individual needs of service users are generally met by an adequate number of trained nurses /care assistants and ancillary staff. Recruitment procedures were robust and in line with employment regulations. EVIDENCE: EMI Unit The staffing of the unit comprises of: Early shift 8 am – 2 pm 2 nurses and 6 carers Late shift 2 pm – 8 pm 1 nurse and 6 carers Night shift 8 pm – 8 am 1 nurse and 3 carers It was noted that there was no RMN trained nurse at nighttime. General Unit The staffing of the unit comprises of: Early shift 8 am – 2 pm 2 nurses and 6 carers Late shift 2 pm – 8 pm 1 nurse and 6 carers Night shift 8 pm – 8 am 1 nurse and 3 carers The staffing level of the units was found to be sufficient and adequate for the needs of the residents in the home. There are adequate numbers of catering, domestic, laundry and maintenance staff. The care manager was supernumerary throughout the working week. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 20 Staff were seen to provide care with sensitivity and there were positive relaxed exchanges between residents and staff. This was noted also particularly in relation to residents with more demanding and repetitive behaviours. There was evidence that residents were treated with respect and dignity. At this time 7 of the 16 care staff working on the EMI unit have completed NVQ2 or above. The owners have recently set up their own NVQ training programme, which is being further, extended to staff. The requirement of 50 of NVQ trained staff is almost met at this time. The general unit NVQ training syllabus was not inspected on this occasion. There is a moving and handling trainer in the home and all staff spoken to had received this training. It is the trainer’s objective to provide moving and handling training for new staff within 2 days of appointment. There has been dementia care training for staff and this is commendable, however, as three residents were identified as having challenging type behaviours, it is a requirement of this report that staff working in this environment receive training in the management of violence and aggression. Two staff personnel files were examined and included, application form, criminal disclosure then CRB, and POVA first checks. Two written references in place and a medical questionnaire completed. There were also completed interview pro formas and check sheets, copy of a birth certificate and photo ID. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,38 The home is well managed and quality assurance was ongoing. Resident’s financial aspects were individually addressed and recorded with safeguards in place. Health and safety requirements had not all been addressed. EVIDENCE: EMI unit Risk assessments relating to resident activity were seen to be in place and were satisfactory. Some staff on this unit have received training in first aid. A check on the roster for the night prior to inspection revealed that there was not a trained first aid person on duty on the unit. All bedrooms have manual self-closing devices. Fire door guards are fitted when residents required bedroom doors to be left open. It was noted that Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 22 some bedroom doors did not close onto the door rebate when allowed to selfclose. All doors must be checked to ensure they fully self-close. General unit On the day of the inspection the general unit was running very well. Routines were well established and all staff knew their duties and responsibilities. Policies and procedures are in place to inform staff of the practices in the home. There was evidence of staff and residents meetings, which had been documented and available for all disciplines of staff. There was safe storage of hazardous substances and staff reported regular servicing of equipment. Establishment Resident’s pocket monies were inspected (20) and all found to be well in order, with spot checks undertaken on the balances remaining in the safe, against the balance maintained on the data sheets. Following discussions with the homes administrator, it was confirmed that new questionnaires are shortly to be sent out to staff and relatives during the week of the inspection. Staff were to get theirs attached to their pay slips. These are part of the ongoing quality assurance programme within the home. Records required by regulation are in place and those sampled were found to be accurate and up to date. All fire records were completed and current. Hot water temperature checks were undertaken weekly. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 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 2 3 2 3 x 3 3 2 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x 3 x x 2 Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 24 yes Are there any outstanding requirements from the last inspection? 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. 2. 3. Standard 9.3 9.4 38 Regulation 13(2) 13(2) 12(1a) Timescale for action Medication given must be signed with for at the point of administration. immediate effect Eye drops and creams must be with dated when opened. immediate effect Footrests must be in place on with wheelchairs unless there are immediate exceptional circumstances and a efect disclaimer signed. All injuries/accidents must be with recorded. immediate effect Relatives must always be with informed of any changes relating immediate effect to the health or welfare of residents. Shower door housing must be 01/08/05 repaired/replaced to ensure safety. Address mal-odour in bedrooms 17, 36 and 37 ( EMI) Replacement of carpets may be required. Remove mattress, hoist and all items stored in the sluice area to ensure adequate access and maintain good infection control Remove chair from en-suite in 01/08/05 Requirement 4. 5. 38.7 7.6 12(1a) 15(2c) 6. 38 23(2c) 7. 26.1 23(2d) 8. 26.6 13(4a) with immediate effect with Page 25 9. 21.1 13(4a) Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 room identified. 10. 11. 12. 30 38.2 38.2 18(1c) 13(3) 23(4) Provide training for staff in the management of violence & aggression Review and ensure that there is a first aid trained person duty at all times Self closing fire doors must close onto the door rebate to ensure protection in the event of fire. immediate effect 01/08/05 01/08/05 01/08/05 13. 14. 15. 26 26 19 13(3) 13(3) 23(2b) Foot operated waste bins must 01/08/05 be in use in clinical areas and the kitchen. Fly screen must be 01/08/05 replaced/installed in kitchen area The hallway carpet ( General 01/09/05 unit) is worn and getting threadbare and this needs to be replaced. Private paying residents must be provided with a contract details their terms of residency in the home. 01/07/05 16. 2 Schedule 4 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 27.1 Good Practice Recommendations Review the non-provision of RMN trained nursing staff at night time. The present arrangements for non-RMN staff should be recorded clearly in the statement of purpose. 2. 15 The purchase of a another freezer is recommended to reduce congestion in the fridges. Park Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Farm Lodge Care Home E51 - E09 s45160 Park farm Lodge Unannounced v.235013 27.06.05 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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