Inspection on 20/02/08 for Park Grange

This inspection was carried out on 20th February 2008.

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

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

Other inspections for this house

Park Grange 26/01/07

Park Grange 23/05/06

Park Grange 05/12/05

Park Grange 01/07/05

Park Grange 17/03/05

Park Grange 25/06/04

Park Grange 26/03/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Park Grange Neville Avenue Kendray Barnsley South Yorkshire S70 3HF Lead Inspector Mrs Jayne White Key Unannounced Inspection 09:15 20th February 2008 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 Grange DS0000018250.V355763.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 Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park Grange Address Neville Avenue Kendray Barnsley South Yorkshire S70 3HF 01226 286979 0113 2370419 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) None Park Care Limited Mr Steven Chance Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. For any two service users under 65 years of age but over the age of 60, may reside at the home 26th January 2007 Date of last inspection Brief Description of the Service: Park Grange is a care home providing personal care and accommodation for up to 36 older people. People can stay on a permanent or short stay basis. The home occupies a central position in Kendray, near Barnsley, close to local shops and other amenities. The home is a three-storey building and has 22 single bedrooms and seven double bedrooms. There is a passenger lift. The home has a garden area that is accessible to people. Park Care Limited own the home. Information of the services and facilities the home offer, including the statement of purpose, service user guide that holds the most current inspection report and terms and conditions/fees to people were on display in the entrance hall. The current scale of charges is £341.50. Additional charges are made for chiropody, hairdressing and day trips and outings. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. We visited the home on 20 February 2008 between 09:15 and 16:15 without giving them any notice. An ‘expert by experience’, Margaret Ferry also assisted with the visit. An ‘expert by experience’ is a person who, because of their experiences of using services visits a service with an inspector. This helps the inspector get a picture of what it is like to live in the service. Margaret’s main focus was talking to people about how they felt their privacy and dignity was respected and what their daily routines and meals were like. She also observed how staff spoke with people and cared for them. Before the visit we took into consideration other information the Commission for Social Care Inspection (CSCI) had received. This included: • An Annual Quality Assurance Assessment (AQAA). An AQAA is a document completed by providers. It gives them the opportunity to tell the CSCI how well they think they are meeting the needs of people using their service. Information contained in notifications from the home about any deaths, illnesses and other events, which affect the health and well-being of people living there. Surveys that were sent to a range of people, asking them about the home. Three came back from people that lived there, three from relatives of people that lived there, two from health care professionals and one from staff. Complaints • • • During the visit we spoke with people that lived there, their relatives or friends, staff, the manager, looked round parts of the building and read some records. We would like to thank the people, their relatives and friends, staff and the manager for their time and co-operation throughout the inspection process. CSCI have reviewed their guidance on requirements, therefore, some requirements have been removed if they would have no direct affect on the outcome of the service provided for people. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 6 What the service does well: The management and administration of the home was based on openness and respect. People, their relatives and staff identified this in their comments when they said, “I think the home is well run by two experienced managers who are mostly supportive of their staff and provide individual care which centres on putting the client first” and “my relative is happy in the environment of the care home. The staff are friendly”. The admission process was well managed. The manager encouraged people to visit before coming to live there and an assessment of peoples’ needs was undertaken to determine the service were able to care for them. People said, “I came to visit before I decided to live here” and “I spent the day here to see if I liked it”. The health and personal care that people received was based on their individual needs. Generally, people living there and their relatives felt they were well cared for saying, “they (staff) always look after me”, “I’m happy and well cared for” and “my relative thinks they need someone with them all the time. They’re given much more that what I could give them at home”. There was mutual respect between people and staff and this promoted peoples’ dignity and privacy. People were assisted to make choices and decisions about their life style and there was a range of social and recreational activities that met people’s expectations. People and their relatives said, “there’s always something going off. Staff take me out on the bus”, “every day there is something going off and I go out on trips to the park and shopping” and “my relative can do whatever they want – stay in bed, play games, play music when she chooses, watch videos in their room”. The service dealt with complaints that were raised and people said they would raise concerns if they had any. People living at the home found the environment comfortable, relaxing and to their satisfaction. On the whole, the home was clean and a programme of redecoration, involving people, was in place. People and their relatives spoke highly of staff saying, “the staff take care of me and get me what I want”, “there’s always someone about”, “they always come to me when I need them” and “all the staff are friendly and helpful”. There were enough skilled staff to support people and on the whole, staff were in sufficient numbers to maintain the smooth running of the service. There were effective quality assurance systems in place where peoples’ views were taken into consideration, which had resulted in overall satisfaction with the service. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcome for standard 3 was inspected. The service does not provide an intermediate care service (standard 6). People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who used the service and their representatives had the information they needed to choose a home that would meet their needs. People moving into the home had their needs assessed, to make sure the home was able to meet their health, social and care needs. EVIDENCE: People and their families said they received enough information about the home before they moved in. This helped them to decide if the place was right for them. They said, “I came to visit before I decided to live here” and “I spent the day here to see if I liked it”. All the people we spoke with were familiar with the home, as they had used the day care facility the service provides. Some people had visited on a short stay basis whilst their families went away. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 10 The manager had stated in the AQAA that a needs assessment for each person was completed prior to admission. They said this was to ensure the home was suitable and able to meet peoples’ needs. They said they encouraged people who were enquiring about coming to live there to spend at least a day in the home before admission. They said this gives people the opportunity to talk to other people to see what they thought it was like and ask staff any questions they might have. We looked at two peoples’ files and this confirmed an assessment had been undertaken. The information obtained established that the service was appropriate for the person and provided staff with information to formulate an individual plan of care. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 7, 8, 9 & 10 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people received was based on their individual needs. The principles of respect, dignity and privacy were put into practice. EVIDENCE: All people we spoke with were pleased with the care and medical support they received and felt they were well cared for. Generally surveys from them supported this. They said, “they (staff) always look after me” and “I’m happy and well cared for”. In contrast, one relative commented, “I am disappointed that my relative’s glasses have disappeared. Also, they have not had their teeth in for weeks, which must be awful when eating”. However, there were other relatives that said “my relative thinks they need someone with them all the time. They’re given much more that what I could give them at home” and “we feel that the care provided in the home is quite good”. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 12 When we spoke to people they described how they had access to health care services to promote and maintain their health care needs. This included hospital appointments and giving them their medication to reduce the effects of their medical conditions. Likewise, all people spoken with said that staff treated them with respect and they were able to spend time in their room if they wished. We saw staff approaching people in a respectful manner and respecting individual preferences. There were good relationships between people and staff. We saw staff knocking on doors before entering and closing toilet doors when in use. This showed they respected the privacy and dignity of people. On the whole peoples’ clothing was clean, as was their hair and nails. This established staff were maintaining respect and dignity for people. For the most part, people were wearing their glasses and teeth, promoting their ability to see clearly and eat without difficulty, maintaining their dignity. We looked at two plans of care. The files were tidy, well organised and the information was easy to find. The plans contained good profile information, records of medical treatment and risk assessments of falls, moving and handling and nutrition. The record indicated reviews were held. Generally, the daily reports contained basic information to describe the action taken by staff to meet the person’s personal, health and social care needs identified in the plan. For instance, diet and fluids taken well but not what this was, for example, drank a cup of tea and ate a poached egg on toast for breakfast. This could be improved. In general, the plans confirmed the care people said they received and what staff said they did to care for people. People said they were satisfied with the way their medication was managed. We saw people being given their medication. They were given their medication in small pots, which meant the medication was not handled. People were given a glass of water when they were given their medication to help them swallow it. This highlighted good hygiene and recording practice and respect for people. The medication was securely stored. The medication trolley used for storage was clean and tidy and temperature records of the fridge where medication was stored were maintained. Staff responsible for administering medication had received medication training, including the procedures to be followed. There had been one occasion when they had not followed the procedure in place for visiting professionals to administer medication. This had resulted in a medication error. When we spoke to staff they were now clear what this procedure was. On the whole, medication received was clearly recorded on the person’s medication administration record and medication administered had been signed for. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 12, 13, 14 & 15 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were assisted to make choices and decisions about their life style and the social and recreational activities available met people’s expectations. EVIDENCE: On the whole, people said there were activities arranged that they could take part in. They said, “there’s always something going off. Staff take me out on the bus”, “every day there is something going off and I go out on trips to the park and shopping”. Relatives felt the service supported people to live the life they choose and one commented, “my relative can do whatever they want – stay in bed, play games, play music when she chooses, watch videos in their room”. Peoples’ bedrooms gave the impression it was the person’s private space that they could personalise it how they wished. They had individual colour schemes and held personal items of the person. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 14 There was a comfortable, relaxed atmosphere with good relationships between people and staff. There was music playing, with people singing along and banter between people and staff. We saw people able to spend the day as they wished, following their preferred routines with the majority of people spending their time in the lounges. There were two members of staff that provided a programme of activities for people during the day. Today, four people were seen playing snakes and ladders, another four Doris’ day out and other people sat in the lounge a game of magnetic darts if they wished. This provided some physical activity for people and also mental activity in scoring and calculating money. One person had been nominated as the person to record the scores. When activities were not being undertaken people were given attention by staff, who chatted with them. People went out on trips either accompanied or alone. The next organised trip was to a fish restaurant. We saw people being visited by their relatives. Relatives said staff were ‘welcoming’ and ‘friendly’ when they visited and that they could visit ‘at anytime’. People said they always or usually enjoyed the food they were served. One said, “the food’s good. I have plenty to eat and they give me what I want”. A relative said, “my relative enjoys their food”. The weekly menus for January to April, which had been decided between staff and people living there at their monthly meetings, were displayed in the hallway. We looked at the menus and saw that there was a variety of different foods offered. The dining room was clean and bright making it a welcoming environment for people to eat their meals. The tables were set with cloths and cutlery and the lunch time meal for the day was displayed. We saw the lunchtime meal being served. It was braising steak, chips and mixed vegetables and pears and cream. There was a relaxed atmosphere and people were given sufficient time to eat and plenty of attention was provided by staff. This made it an enjoyable experience for people. There was conversation between people and staff. Staff were courteous and respectful to people when they served their meals. We saw carers assisting people who needed help to eat in an appropriate manner. Between meals, people were offered tea, coffee and biscuits. We felt introducing further choice, for example, water, juice and fruit that had been cut up could improve this. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 16 & 18 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were able to express their concerns and had access to a complaints procedure. They were protected from abuse and had their rights protected, but adult safeguarding policies and procedures were not followed. EVIDENCE: When we spoke to people they were satisfied with the service they received and that they had ‘no complaints’ or ‘grumbles’. They were clear that if they did they would speak to ‘Steve’ or ‘Sue’ (the manager and deputy). Generally, surveys confirmed people, their relatives and health professionals knew how to complain. Their comments included, “I would see Steve or Sue”, “my family would do this on my behalf”, “I work in a nursing home, so I know the procedure of making a complaint”, “I believe I would contact your department or the local social services” and “we have had no cause to raise any concerns about the care”. We saw there was a complaints procedure displayed in the hallway for people to look at, should they wish to complain. It told people how to make a complaint and who would deal with them. We spoke with the manager about putting this lower down so people could see it more easily. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 16 There was a record of all complaints. It was discussed with the manager how the recording of complaints could improve. One complaint had been made directly to CSCI. The provider investigated the complaint. A response was made to the complainant and the CSCI. This demonstrated the service had acted on the complaint and provided supporting information of the outcome. The AQAA stated the manager had now undertaken formal training in the safeguarding of adults. The manager said this had clarified and updated their knowledge of local adult protection protocols. He had obtained a copy of the local multi agency procedures for adult safeguarding. However, subsequent to the site visit and whilst the first draft report had been issued an anonymous complaint was made to social services alleging abuse. When social services pursued this through adult safeguarding procedures, the manager was aware of the allegation, had conducted an internal investigation and had not reported the allegation to social services or CSCI. This meant he had not complied with the home’s own procedures, the local multi agency adult safeguarding procedures and the care home regulations. The manager acknowledged this at a meeting in respect of the allegation and that he now realises he should have done this. This resulted in a further issuing of the draft report and the judgement for this section being amended to adequate from good. The training matrix identified staff had received training in safeguarding adults, although this needed updating. When we spoke with staff they were clear about who they must report abuse to. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 19 & 26 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. On the whole, the building and its environment were clean, well decorated and well maintained. This meant people found the home comfortable, relaxing and to their satisfaction. EVIDENCE: When we spoke with people they told us they thought their home was comfortable and were pleased with their living environment. They said they had a comfortable bedroom, which had been individually decorated as they chose. People had personalised their room with pieces of their own furniture and possessions. They said it was always kept ‘clean’ and ‘fresh’. They commented, “staff work hard to keep it clean. My bedroom is clean and tidy”, “my relative is incontinent and therefore it is difficult to keep their room fresh. However, the staff try hard and the lounge is generally fine”, “very pleased the Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 18 drive has been resurfaced. This makes a marked improvement” and “we always think the home is clean and tidy and no unpleasant smells”. We saw people moving around the home as they wished. They had access to all indoor and outdoor facilities. There were three lounge areas, a conservatory and a dining room. They presented a pleasant and homely environment for people to live. Areas were pleasantly decorated and there were homely touches of pictures and flowers. We noticed that peoples’ names on their bedroom doors were in small print and too high up for most people to read and therefore could be improved by adapting this. On the whole, when we looked round the home it was tidy, clean and fresh, which again promoted a comfortable and homely environment. Refurbishment of some bathrooms would improve the environment. We did see vacuum cleaners being stored on the landing areas at the top of the stairs. This could present a tripping hazard to people and staff. The manager had identified in the AQAA the service has an ongoing redecoration and improvement programme. The last 12 months have seen several bedrooms being redecorated and recarpeted, new benches being bought for use outside, the driveway being resurfaced and the installation of a new central heating boiler. Further plans include devising a plan to paint the exterior. The AQAA said people were involved in the redecoration of the home, choosing colour schemes and furnishings. This was confirmed in the minutes of their monthly meeting that was displayed in the hallway. They had discussed colour schemes for the redecoration of the lounge areas. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 27, 28, 29 & 30 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff were sufficiently skilled to support people, however, training needed to be kept up to date to maintain these skills. On the whole, staff were in sufficient numbers to maintain the smooth running of the service. EVIDENCE: People and their relatives spoke highly of the staff that cared for them. They said staff always listened and acted on what they said and there were usually sufficient staff available to meet their needs. Their comments included, “the staff take care of me and get me what I want”, “there’s always someone about”, “they always come to me when I need them”, “all the staff are friendly and helpful” and “my relative is happy in the environment of the care home. The staff are friendly”. We saw good relationships between staff and people. Staff responded to assistance when required and there were sufficient staff were on duty to provide assistance. There were ancillary staff employed to ensure standards relating to food, meals and nutrition were met and maintain the home in a clean and hygienic state. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 20 The staff survey we received said, “most of the time the home is well staffed, particularly Monday – Friday. At the weekend, the manager tries to maintain the level of care staff, however, in the past six months there has been a lot of changes in staffing which I think has resulted in gaps in the rota – again particularly at the weekend. Sometimes staff get bogged down with the practicalities of care, leaving insufficient time to entertain and stimulate clients!” This was confirmed when we spoke to staff, but they said this had improved. When we looked at the rotas they were not always clear as to how many staff were on duty as some staff had ticks against their names, not hours that were worked. The rotas did confirm there were fewer staff on duty on a weekend than in the week. The manager said that when they knew they would be short staffed, agency cover was used. Eighty four per cent of staff working at the home held NVQ Level 2 in Care or equivalent, with the rest of the staff working towards it. They had received other training such as moving and handling, infection control, health and safety, safeguarding, first aid and food hygiene. However, when we spoke with staff and looked at their training records this identified the training needed updating. The training matrix that the manager kept, highlighted some of this training had already been planned. There were some copies of qualifications and certificates of training in place on files, to verify the authenticity of the training, but this could be improved. There was no person qualified in first aid on shift to support people in an emergency. When we spoke to the manager they had not completed a risk evaluation of this situation, which could place people at risk. We looked at the recruitment file for one member of staff. A recruitment process had been followed including the completion of an application form, a Criminal Records Bureau check and obtaining references. There were gaps in the person’s employment history, which had not been confirmed. The process also identified a reference had not been obtained from the last employer. The value of these, in safeguarding people was discussed with the manager. Park Grange DS0000018250.V355763.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. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 31, 33, 35 & 38 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home was based on openness and respect. It had effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The AQAA stated the manager was a registered nurse and had worked in care homes for approximately 18 years. The AQAA stated he was to commence NVQ Level 4 training in 2008. This had given him good experience in caring for people in a care home setting. He had a good knowledge of the needs of people, was committed to providing a good quality service and communicated a clear sense of leadership to staff. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 22 When we spoke to staff, it identified staff morale was good. Staff spoke highly of the manager as did people that lived there. One said, “I think the home is well run by two experienced managers who are mostly supportive of their staff and provide individual care which centres on putting the client first”. Staff felt that there was good teamwork within the home and that they enjoyed working there. The quality assurance system included a process whereby the views of people were taken into consideration, in addition to the manager’s quality assurance audit. The latest quality assurance survey was provided. In summary, feedback was on the whole positive, complimentary and all those surveyed expressed satisfaction with the service. It identified action taken and changes for the future. Some of the changes could be seen on our visit. The provider also visited the home and more consistently he had completed a report of those visits identifying and taking action to improve the service. People looked after their finances if they wished and had the capacity to do so. Where the service looked after money on behalf of people, financial systems were in place to safeguard the money. We looked at the records in place for two people. Written records of all transactions were maintained, with two signatories to confirm the transaction and receipts. There were safe facilities to store the monies. When we looked round the building hazardous substances were securely stored. Fire exits were free from obstructions, which should make it easy for people and staff to leave the building should there be a fire. We saw good moving and handling techniques, which meant people were being moved safely. When we spoke to staff they said there was sufficient equipment and aids and adaptations to move people safely. In the AQAA it stated accidents were monitored and audited and a 72 hour review was completed. The audit identifies anyone at risk from falls and action is taken. This was confirmed when we looked at accident records. The AQAA stated maintenance and servicing was in place for electrical circuits, the lift, fire detection and fire fighting equipment, emergency call equipment, the heating system, soiled waste disposal and gas appliances. When we looked at the servicing certificate for the hoists it identified one where it recommended the hoist was not used. When we spoke to people they said they sometimes had their bath in this bathroom. When we looked in the bathroom the floor was wet, which indicated the bath had been used that day. This could place people at risk of injury and the manager was told to ensure the bath was not used until it was repaired or replaced. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 23 We saw that a fire risk assessment was in place and the AQAA stated staff were provided with fire training annually and their knowledge checked during supervisions, fire equipment is checked weekly and fire drills are carried out monthly. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 24 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 25 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 OP18 Regulation 37 (1) (g) Requirement Any allegation of misconduct by a member of staff who works at the care home must be reported to CSCI and social services. This is so that they can assess the action to be taken is sufficient to safeguard people. An alternative storage facility must be found for the vacuum cleaners, so that they do not present a tripping hazard to people and staff. The recruitment process must demonstrate a full employment history, together with a satisfactory written explanation of any gaps in employment. Previous timescale of 31/03/07 not met. A risk assessment must be undertaken to determine if staff on duty are sufficiently trained in first aid should an accident take place. The outcome must be acted on. The parker bath in the downstairs bathroom must not be used until it is repaired or replaced. This is so peoples’ DS0000018250.V355763.R01.S.doc Timescale for action 29/04/08 2. OP19 OP38 13 (4) (a) 31/03/08 3. OP29 19 20/02/08 4. OP30 OP38 13 (4) (c) 20/02/08 5. OP38 13 (4) (b) 20/02/08 Park Grange Version 5.2 Page 26 safety is not compromised when they are having a bath. 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. Refer to Standard OP29 OP30 Good Practice Recommendations To support a thorough recruitment process that safeguards people, a reference should be obtained from the staff member’s last employer. Monitor more closely when training needs updating and arrange for this in advance. This will make sure staff keep up to date with the knowledge and skills for their role. Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Park Grange DS0000018250.V355763.R01.S.doc Version 5.2 Page 28 - 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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