Inspection on 31/05/06 for Park Farm Lodge Care Home

This inspection was carried out on 31st May 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Park Farm Lodge Care Home 12/09/07

Park Farm Lodge Care Home 22/11/05

Park Farm Lodge Care Home 27/06/05

Park Farm Lodge Care Home 25/01/05

Park Farm Lodge Care Home 08/06/04

Park Farm Lodge Care Home 19/11/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Park Farm Lodge Care Home Park Farm Road Tamworth Staffordshire B77 1DX Lead Inspector Mr Keith Jones Key Unannounced Inspection 31 May 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park Farm Lodge Care Home Address Park Farm Road Tamworth Staffordshire B77 1DX 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) 01827 280533 01827 288544 www.fshc.co.uk Tamaris Healthcare (England) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Laura Ann McCormick Care Home 80 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (40) Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 40 Dementia (DE) - Minimum age 60 years on admission Date of last inspection 22nd November 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 floors. Adequate parking is available to the front and side of the property. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted with the Registered Care Manager, Tamaris Health Care Regional manager and senior nursing staff. The last inspection report was discussed, and it was noted that there were no outstanding requirements or recommendations. The tour of the home was carried out in a relaxed, courteous and professional manner, everyone concerned expressed confidence in the atmosphere, liking it to a family feeling. All the service users approached were highly complimentary of the care, service and attention they received from a willing, attentive care team. There were 64 service users on the day of inspection, 32 categorised as requiring nursing care for the elderly mentally ill, and 32 with physical disability. Eight service users were case tracked confirmed the establishment of a well run, very comfortable and ‘homely’ establishment. Relatives who were present were equally complementary of the family approach to care, the freedom they enjoyed and the involvement that the manager and her staff encouraged. Everyone appeared comfortable and at ease with their surroundings. The Inspector presented the new inspection process under IBL (Inspection for Better Lives) initiatives, discussing change in emphases, including an appraisal of issues of diversity. It was acknowledged that policies and procedures are in place throughout the Company, and that staff are aware of the issues involved. A sample review of the administration confirmed solid practice and effective management. Discussions with service users and staff over the general standards of care and service proved to be enlightening and very constructive. A full report was offered at the end of the inspection with open discussion involving the Regional and Registered Care Manager. Overall the attitude in meeting caring and organisational demands is highly commendable, with forward thinking, planning and application, contributing to a very satisfactory service. What the service does well: Park Farm Lodge offers a high standard of care and service, is well organised, with a committed care management team. Emphasis goes into involving the residents and their families in the process of care, ensuring a highly personal approach to meeting individual needs. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 6 Assessment procedures and care planning is of an excellent standard, offering detailed information on each resident’s progress in the meeting of objectives. The housekeeping and support services all contribute to the team approach, and are recognised by the management for their efforts, and the Inspector for the service observed. Maintenance of good staffing levels, staff training and supervision are well established in safeguarding the interests of residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 The quality in this outcome area is “good.” This judgement is based on the examination of the homes policies, procedures, practices and discussions with management. Park Farm Lodge ensures that prospective residents have the necessary information to enable an informed choice to be made. Aims and objectives, terms and conditions are clearly presented in a way to facilitate easy understanding of services and standards of care. The provider ensures that the admission process is a reflection of a joint understanding that residents are aware, and that staff are able to meet expectations to realise a comfortable transition. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 9 EVIDENCE: The pre-inspection questionnaire was received in good time and its effective completion facilitated an informative and pleasing inspection. The updated Statement of Purpose and guidelines reflect an expression of philosophy, and have been well established in representing the foundation on which the home operates upon. It presents an excellent description of the Home’s aims and objectives, philosophy of care and terms and conditions. All the requirements prescribed in Schedule 1 are addressed, presenting Four Season’s policies with Park Farm Lodge’s identity. The contract document reflects changed circumstances and conditions, including an identification of allocated bedroom agreed. The Provider adheres to a strict admission policy of personal supervision of the pre-admission assessment. Case tracking of eight resident’s files demonstrated the presentation of a highly personal approach to prospective residents and their relatives on pre-admission. A detailed assessment was examined and found to collect a full profile of physical and psychological needs, as well as social, cultural and environmental circumstances. Follow up with discussions with those residents confirmed the strong understanding of care needs and expectations in managing those needs. An appraisal is made, and discussed, to ensure the home can satisfactorily meet those needs. Case tracking and discussion with service users confirmed that this standard continues to be well met. Following an assessment the senior nurse assessor determines the suitability of the application in view of the facilities available, and at the capacity of the home, to manage the individual and any special needs. Likewise the applicants are informed of those facilities and are encouraged to seek clarification concerning the general and specific services available for the prospective service user. Case tracking confirmed that a valuable exchange between service users and assessor took place and resources made available. These resources were seen to be an appraisal of staffing skills, equipment and general environment. Prospective service users and their relatives are able to visit and assess the quality, facilities and suitability of Park Farm Lodge at any reasonable time, to meet with staff and management. At all times relatives are involved throughout the process. A relative’s forum has been established with a commitment to develop the liaison further. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 The quality in this outcome area is “good.” This judgement is based on the examination of eight care plans plans, discussions with service users, staff, managers, general observations and the homes medication system. The service users’ assessment provides the base from which care planning is formulated. It is recognised that this reflects an individual profile of needs, discussed fully with family. The home has a GP provision that visits the home frequently. The Statement of Purpose, admission assessment and care plans are geared to engender a sense of individuality and privacy. The Inspector was impressed with the confidence and closeness within the Home of staff, residents and visitors, and the mutual respect that prevailed. There exists a straightforward, yet effective medicines administration system, accurately monitored and actioned on two floors. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 11 EVIDENCE: Four case records were examined on each floor, and found to offer a clear, well balanced, up to date and accurate appraisal of requirements. Reviews were done on a minimum of once a month, usually more often, as needs dictate. Case tracking of those eight residents confirmed the depth of care planning supported by a solid foundation of organisation and quality services. The system would benefit with a clear record of date of review with family. The home has good links with specialist services – continence advisor and tissue viability. A profile of the service user’s social, physical and psychological status offered an individual plan of care, based upon a model of daily living, to be implemented and frequently reviewed. Each service user’s health, personal and social care needs were seen to be assessed in an individual plan of care that is reviewed monthly, including service users and relatives views, to reflect their changing needs. That review is more frequent, dependant upon the individual’s needs and clinical condition. It was recognised that the system is to be replaced with a process that appreciates and accentuates the holistic and social needs of the residents and their families. A tour of the premises evidenced that there was a range of pressure relieving equipment, and examination of service user plans found that all are assessed in relation to pressure sore risk, falls risk and nutritional risk, with monthly observational checks recorded. It was advised that the trained members of staff should be firmly in control of that process, when several residents showed unlikely changes in weight gains. The administration of medicines on both floors adheres to procedures to maximise protection to service users. The storage was secure with satisfactory added security for controlled drugs. A controlled drug register was examined and found to be in order. Family and friends have relative freedom of visiting, those spoken to remarking on the importance of maintaining social contact. The Statement of Purpose clearly and openly states that the wishes concerning arrangements after death would be discussed and respectfully carried out, ascertained as soon as possible after admission. The spiritual needs of service users were recorded and observed by the staff with due respect. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The quality in this outcome area is “good.” This judgement is based on discussions with service users, examination of records in relation to social activities undertaken and general observations during to course of the inspection. Routine is seen as flexible to acknowledge individuality, yet maintain a focal point for service users to latch on to without dictating events. Service users’ life-styles and interests are recorded in their care plan, discussed with their relatives prior to admission, and documented as far as possible to enhance a position of supported independence. Personal choice and relative selfdetermination are respected in policy and action. Those who wish to bring in personal possessions are encouraged to do so. Service users were offered a varied and nutritious choice of meals from a 4week rotating menu. Special diets were accommodated with the cook making every effort to engage with service users to discuss personal preferences. Staff were seen to offer discreet assistance to those who required it. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 13 EVIDENCE: Discussions with service users and staff clearly identified a relaxed atmosphere in which the service user’s needs were respected. A routine exists to establish a framework for managing the home, not as a yardstick for service users to comply with. Several residents expressed their appreciation for the freedom they enjoyed, with the security that there are familiar events to the day they could relate to. Those service users’ rooms inspected showed a significant influence of personalisation in the inclusion of belongings, some furniture and general décor. It was particularly pleasing to see the emphasis on personalisation in the EMI unit. The activity co-ordinator who had been off work for several months is to return the next week. Socialisation records were examined and found to be meaningful. The garden areas have been repaired and in use during good weather, offering a pleasing and safe environment. The good standards of catering at Park Farm Lodge offered an excellent service, to which service users spoken to were complimentary of all aspects of quality, with the occasional swipe at quantity, which was evidently a personal point. A menu on a four weekly cycle offered a wholesome, varied and excellent choice. An excellent lunch was served during inspection, with choices available, served in choices of dining rooms. There was an observed wear and tear of furniture and of décor in two rooms, identified for early upgrade. The kitchen is to have its renovation the following week. Plans to accommodate the four days when the facility is down are well formulated with staff and residents clear on what is needed. Staff were seen to offer discreet assistance in offering food to those who needed help. The choice of dining room, lounge or bedroom was at the discretion of service users. The kitchen was inspected with the cook and found to present a well equipped and organised area. All fridges and freezers were well maintained and checked daily by the kitchen staff, and a cleaning schedule was in place. Work on flooring and re-tiling is to be done the next week. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 The quality in this outcome area is “good.” This judgment is based on the examination of the homes complaint procedure and the recruitment procedure of staff to ensure the protection of service users. The home had a meaningful complaints policy, clearly identifying the CSCI as a resource to approach with a complaint or grievance. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. The new arrangements for handling complaints in the spirit of Inspection for Better Lives were understood. Service users’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. EVIDENCE: The complaints policy was seen and records examined. There were few minor complaints assessed, all dealt with at the source. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. The CSCI had been involved in two allegations involving vulnerable adults. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 15 One had resulted in no further action, one still ongoing. The Inspector expressed his concern that this issue had been pending for three months, due to receiving of reports. The Care Manager stated that an early resolution was imminent. Case tracking confirmed the effectiveness of a care manager and staff sensitive to service users needs and readiness to test the robustness of their information and report structures. As part of the process of encouraging self-determination a policy exists to be able to offer advocacy services should they be required. Family involvement has been the usual means of representation in the past. Residents’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. This process was evidenced on examination, and case tracking as previously reported upon. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. It was advised that abuse be established as a regular feature on the annual training programme for all staff. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 The quality in this outcome area is “good.” This judgement was based on discussions with service users, staff and a tour of the premises. The home is well appointed to meet the needs of an elderly population of service users in providing a safe and comfortable environment. Bedrooms were well maintained to meet service user’s personal preferences; the outcome is a comfortable and familiar private domain that reflects the service user’s preferences. There is evidence of an awareness of health and safety issues being high on training and supervision priorities. Individual rooms are presented as highly personalised and inviting individual domains. The Home continues to present a clean and pleasant, odour-free atmosphere, much to the credit of staff. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 17 EVIDENCE: External access is satisfactory for visitors, service users take advantage of attractive gardens and grounds; pathways were safe and recently attended to. On admission the provider or care manager assesses each individual service users’ needs for equipment and necessary adaptations. Internal access was facilitated with ample fittings of hand and grab rails, in adequate, well-lit and airy corridors. Wheelchair access was satisfactory throughout all areas of the home. Bedrooms were well maintained to meet service user’s personal preferences. On inspection most bedrooms were highly personalised, with some displaying service user’s own furniture, and most with personal belongings. It is the policy that on bedrooms becoming vacant that each room is reappraised for redecoration. There is throughout a good standard of furnishing complimented with a variety of personal belongings. A locked facility and lockable bedroom doors were made available on request, following suitable risk assessment. The evidence seen on inspection of service user’s rooms, and on discussion with the individual service users and family, assured that this standard was well met. The Care Manager is to review the type of lock available to maximise secure access and minimise risk. All communal areas are of a high standard, offering social as well as private reflection, as the mood takes. A large lounge space allows activities to be presented in a very pleasant, animated area of the home with furniture and fittings of good quality. The dining areas were adequate, and corridors wide enough for wheelchair access, well lit and with sufficient handrails. The external and internal environment was well maintained and secure. Heating and ventilation were found to be satisfactory and lighting was domestic in style. All rooms had on-suite facilities, and aids, adaptations and equipment were available throughout the Home. The standard of cleanliness was of a good standard throughout. Two bedrooms had a malodour, with one of an unacceptable status. Immediate remedial action is to be taken to counter the problem. The damaged and aged carpet cleaner needs replacing. An effective call system is installed; care staff reacted speedily to tests. The care manager expressed a willingness to meet any reasonable demand for special needs. The shower room that had presented a risk had been attended to but still needs a new floor surface and tackle the essence of privacy. The Care Manager will look into the suggested alternatives. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 18 Several service users spoken to expressed a sense of belonging and satisfaction in the quality and presentation of their living areas. Kitchen presentation showed good standards of cleanliness and evidence of sound food hygiene practices. The laundry was well organised and equipped to a good standard. COSHH regulations were displayed and relevant to solutions in use, although storage rooms need high-visual posters. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality in this outcome area is “good.” This judgement was based on the examination of staff files, working rotas and discussions with staff. The staffing levels in relation to the number of service users in residence and their dependency level was suitable to meet the needs of service users. Staffing stability has been maintained with consistent levels to ensure equilibrium between numbers, skills and qualifications, with a strong presence of long serving experienced staff. Care bank are occasionally used, agency rarely, with agreed overtime and flexible rostering to accommodate shortfalls. The management have established a comprehensive procedure for interview, selection and appointment of staff. The thoroughness of staff selection has a significant effect upon the provision of cares to ensure protection of service users. All staff receive training in care issues within the home from registered nurses and external trainers. EVIDENCE: The inspection was conducted with the care manager and unit managers, and it was confirmed that there were 64 service users in residence on the day of inspection, 32 EMI and 32 with physical disability. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 20 The duty rotas for weeks commencing 01/05/06 through to the 29/05/06 were available, inspected and staffing levels were seen to be satisfactory. The overall general skill mix and numbers of staff working in the home meet the needs of the service users. It was acknowledged that the Home has been operating on 80 occupancy for several months. The daily care staffing rota showed adequate balance between skills, qualifications and numbers to provide a foundation for a good standard of care. Shifts are supported with full participation of unit managers, with the Care Manager supernumerary. Agency coverage has been rarely used since the last inspection; overtime and flexible rostering meet shortfalls. An average daily coverage was recognised for each unit: a.m - 2 RN 5 carers p.m - 1 RN 4/5 carers N.D - 1 RN 2/3 carers The catering, domestic and laundry hours were determined and found to be appropriate for the size of the home and the needs of the residents. The home has an activity organiser for 30 hours per week. The care manager emphasised the home’s commitment to training and to achieving targets for NVQ level 2. There are 13 staff with NVQ level II and level III. There are 22 certificated first-aiders in the home’s staffing establishment. Six staff files were sampled and found to be well organised and up to date, following a review of procedures. It was evidenced that CRB checks have been made and contracts of employment are up to date. Ongoing personal and training records were kept secure in accordance of the Data Protection Act 1998. Policy clearly states an equal opportunity position. Three on-duty members of staff were interviewed, each expressing their working conditions openly and with confidence. Each individual was complementary as to the level of training and supervision they receive. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 The quality in this outcome area is “good.” This judgement was based on discussions with the Registered Manager and Regional Manager, the examination of the home policies and procedures with regards to the effective management of the home, general observations during the process of the inspection and discussions with service users and staff. The care manager Laura McCormick offers a considerable resource of experience and skills, which are reflected in the high standing in which Park Farm Lodge is held by residents, their relatives and the community alike. The style of management was seen as by direct observation, and by discussion with service users, relatives and staff, and that a very open and positive attitude prevails, enhancing the home’s ‘family feel’ and homeliness. There was strong evidence of openness and honesty in speaking with service users, relatives and staff in which day to day events and episodes were freely discussed. On-site inspections offers evidence of a management firmly in control, well organised and prepared to facilitate meaningful, delegated responsibilities to an efficient care management team. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 22 EVIDENCE: The care manager has demonstrated competence in running Park Farm Lodge in influencing a solid Statement of Purpose and policy portfolio that has been implemented, to achieve a high standard of set aims and objectives. Staff meetings are held regularly in which staff are encouraged to participate and influence the management and direction within the home. The inspector observed at first hand the confident interrelationship that exist not only between management and staff, but also between staff and residents. The Care Manager and Registered Provider have reinforced the presence of quality assurance with a monthly audit of standards, and regular review of risk assessments. It was agreed that a comprehensive risk assessment of the environment and facilities will be made. There was strong evidence of openness and honesty in speaking with service users, relatives and staff in which day to day events and episodes are freely discussed. Evidence was secured to confirm a quality monitoring system has been introduced, based upon audit of standards, care plans and feed back from service users and relatives. Standards are discussed at staff meetings, daily reports, direct observation and involvement and one to one staff meetings. The procedures manual was randomly examined and found to offer a very comprehensive reference. Fire safety remains high priority for all staff evidenced in routine maintenance checks, regular fire drills and frequent staff training sessions. Discussion with the care manager indicated that supervision sessions and individual training programmes are areas of importance, maintained to a meaningful degree. The Statement of Purpose is clearly recognised as the foundation for providing a high standard of care through effective quality assurance and adherence to working policies, procedures and practices. A sample of administrative, maintenance and care records were examined and found to offer an accurate reflection of a service committed to providing a safe and comfortable environment for elderly service users. Accidents were seen to be addressed, risk assessed, actioned and recorded in an effective way, with access to Riddor if needed. Incidents reported to CSCI were discussed, prompting recognition and action. Excessive summer temperatures were considered and an action plan is to be reviewed. 16 comment forms from residents and relatives were received and discussed. The administration and management of the home is efficient, uncomplicated and sensitive to the needs of service users. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 4 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 4 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP21 Regulation 13(4)(a) Requirement The flooring in the shower areas on EMI to be renewed, with attention to privacy of the individual. Timescale for action 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 OP38 OP19 Refer to Standard OP26 OP24 Good Practice Recommendations Attention to malodours and replacement of carpet cleaner to maintain standards of hygiene. Review bedroom and communal furniture for repair/replacement. That COSHH posters be secured in areas of chemical usage and storage. That a full unit risk assessment programme be updated. Park Farm Lodge Care Home DS0000045160.V296480.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Office 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 DS0000045160.V296480.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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