Inspection on 23/05/06 for Park Grange

This inspection was carried out on 23rd May 2006.

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

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

Other inspections for this house

Park Grange 20/02/08

Park Grange 26/01/07

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Park Grange Neville Avenue Kendray Barnsley South Yorkshire S70 3HF Lead Inspector Mrs Jayne White Unannounced Inspection 23rd May 2006 09:15 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.V294412.R02.S.doc Version 5.1 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.V294412.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Park Grange Address Neville Avenue Kendray Barnsley South Yorkshire S70 3HF 01226 286979 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.V294412.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2005 Brief Description of the Service: Park Grange is a care home providing personal care and accommodation for 36 older people. 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 residents. Park Care Limited own the home. On 23 May 2006 the fee to reside at the home was £315 per week. The manager said this would increase on 2 October 2006 to £327.50. There were additional charges for chiropody and hairdressing and some social activities. Information of the services and facilities the home offer, including the service user guide that holds the most current inspection report and terms and conditions/fees to residents and prospective residents is kept in the office. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors, Jayne White and Sue Stephens, undertook this key unannounced inspection. The inspection took place over six and three quarter hours from 9:15 to 16:00. As part of the inspection process twenty seven questionnaires were sent to residents and seven to general practitioners to obtain their opinions of the home. Five questionnaires were returned by residents and four from general practitioners. On the day, opportunity was taken to make a partial inspection of the premises, inspect a sample of records, observe care practices and talk to residents, their advocates, staff and the manager. The inspectors spoke in detail to five of the staff on duty about aspects of their knowledge, skills and experiences of working at the home and five residents about their opinions on aspects of living at the home. Also taken into account was other information received by CSCI about the service since the last inspection. In addition the CSCI have reviewed their guidance on requirements, therefore, some requirements have been removed if they had no direct evidence of service user outcome, or reworded. The inspectors wish to thank the residents, staff and managers for their time and co-operation throughout the inspection process. What the service does well: Residents were highly satisfied with the management of the home. The atmosphere in the home was lively with music playing and residents and staff laughing and chatting and residents were comfortable to give their opinion of the service. Residents’ comments of their home included “bedroom very comfortable”, “couldn’t be better”, “so comfortable”, “it’s home from home”. All residents that were spoken with said their needs were met and they were happy with the care offered to them. If they did have any complaints residents were confident their complaints would be listened to and acted upon and said “he (Steve, the manager) will put things right”, “nephew visits regularly and would help sort any problems out if necessary” and “if there was something wrong I could go to Steve”. Discussions with residents’ identified how they were helped to exercise choice and control over their lives and how the lifestyle within the home met their preferences, interests and needs. Comments included “can chat with manager or staff at any time”, “in summer we go outside”, “we do dancing and have Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 Page 6 music”, “we have nice sing songs”, “there is nothing you could fault”, “I knit and I crochet”, “it’s relaxing here”, “they take us out”, “we go to places to have a meal”, “we have nice games and things we like”, “there’s a lady who comes dancing and a man plays the organ”, “I can go to bed when I want”, “in the morning staff give us a little call and tell us what time it is”, “staff pick clothes out that are nice for you”, “play dominoes” and “it’s grand here”. Residents maintained contact with family and friends and members of the local community as they wished. Residents received a diet that satisfied their requirements in a pleasant dining area. Comments included “food very good and always a choice”, “food is perfect”, “good”, “meals are lovely – especially fish and chips” and “too much – I’m getting fat”. The positive comments by residents demonstrated the staffing arrangements were sufficient to meet the needs of residents. The staff spoken with had a good knowledge of residents care needs and were able to demonstrate the services that the home provided. Residents described staff as “marvellous”, “kind”, “lovely” and that they worked hard. Residents who moved into the home, had, had their needs assessed and were provided with access to health care services to promote and maintain their health care needs. What has improved since the last inspection? What they could do better: The manager was asked to review, in discussion with residents the types of aprons provided at meal times to improve the dignity of residents. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 Page 7 Staff needed further training in the protection of vulnerable adults and fire training to reinforce their knowledge in regard to the protection of vulnerable adults and the action to take in the event of a fire to ensure residents were safe. There were aspects of the environment where housekeeping arrangements needed to improve to provide a safe environment for residents to live including potholes in the drive way, wobbly chairs in the dining room, emptying ash trays that are full, removing a broken pot and clump of earth in the outside sitting area and attention to an area in a bathroom where there was a protruding pipe. The improvement plan submitted by the manager of the home on 01 August 2006 stated action had been taken to address the chairs in the dining room, emptying ash trays that are full, removing the broken pot and clump of earth and attending to a protruding pipe in the bathroom area. The improvement plan stated the owner, Mr Shipley is dealing with the resurfacing of the driveway. Improvements were required with some of the records kept by the home to safeguard residents’ rights and best interests. There was lack of detail in the residents’ individual plan of care in regard to the management of residents’ behaviour and financial record. In addition, a thorough recruitment procedure was not demonstrated. 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 Grange DS0000018250.V294412.R02.S.doc Version 5.1 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.V294412.R02.S.doc Version 5.1 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 the following standard(s): The outcomes for standards 2, 3 & 6 were inspected. Residents had a written contract/terms and conditions with the home. Residents had their needs assessed before they moved into the home. The home did not provide an intermediate care service. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: All questionnaires returned by residents confirmed they had received a contract. Inspection of three residents’ records identified those residents had been issued a contract/terms and conditions that identified the fee to be paid, room number, the trial period and period of notice. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 Page 10 The inspection of the three residents’ records also identified a basic assessment of need when the residents had moved into the home had been completed. Comments from five resident questionnaires when they moved into the home were “looked round a lot of homes – this one best one – very friendly and no smells” and “nephew checked it all out”. Mr Chance confirmed the home did not provide an intermediate care service. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 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 the following standard(s): The outcomes for standards 7, 8, 9 & 10 were inspected. Residents did have an individual plan of care, however, the plan needed more detail in regard to the management of residents’ behaviour. Residents were provided with access to health care services to promote and maintain their health care needs. Residents were protected by the home’s policies and procedures for dealing with medicines. Residents were treated with respect and dignity, but the manager was asked to review the types of aprons provided at meal times to improve the dignity of residents. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 Page 12 EVIDENCE: Three individual plans of care were inspected on a sample basis. 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. The plan did not identify what action staff needed to take to manage the behaviour of residents. The daily report used words such as demanding, agitated and aggressive to describe behaviour, which labels residents rather that describe their behaviour, for example shouting, pacing up and down and continual buzzing for staff. All residents spoken with and the five who returned the questionnaire said they always received the medical support they needed and comments included “you can see a GP whenever you want” and “I can go to see the GP”. A general practitioner commented “highly satisfactory care home” and “kind staff who seem to know their patients well (not often the case in other homes!!). Residents were happy with the way their medication was managed. Inspection of the medication demonstrated there were records in place for the selfadministration of medication, medication administration records were neat and ordered and the medication trolley was clean and orderly. All residents spoken with said that they were well cared for, staff treat them with respect and they were able to spend time in their room if they wished. Comments from the five questionnaires returned were “well looked after – been here ten years” and “care very good”. Staff were observed approaching residents in a respectful manner and respecting individual preferences. Good relationships between staff and residents were evident. There were areas where the privacy and dignity of residents was respected, for example, knocking on residents’ doors before entering and closing toilet doors when in use. Discussions with staff identified they were aware of the action to be taken to maintain the personal care needs of residents in a timely manner to respect their dignity. At meal times disposable plastic aprons were given and accepted by residents to protect their clothing from spillages. A domestic or household type of apron would improve the dignity of residents who used them and the manager was asked to review the types of aprons provided in discussions with residents. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for 12, 13, 14 & 15 were inspected. Discussions with residents’ and their advocates described how they were helped to exercise choice and control over their lives and how the lifestyle within the home met their preferences, interests and needs. Residents maintained contact with family and friends and members of the local community as they wished. Residents received a diet that satisfied their requirements in a pleasant dining area. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 Page 14 EVIDENCE: Five questionnaires completed by residents said the home always arranged activities they could take part in and a comment included “I enjoy activities every day”. Residents’ spoken with described how they could choose to spend their day and confirmed that they could choose what time to get up and go to bed within reason, accepting the constraints as part of group living. Comments by residents about their lifestyle within the home included “can chat with manager or staff at any time”, “in summer we go outside”, “we do dancing and music”, “we have nice sing songs”, “there is nothing you could fault”, “I knit and I crochet”, “it’s relaxing here”, “they take us out”, “we go to places to have a meal”, “we have nice games and things we like”, “there’s a lady who comes dancing and a man plays the organ”, “I can go to bed when I want”, “in the morning staff give us a little call and tell us what time it is”, “staff pick clothes out that are nice for you”, “play dominoes” and “it’s grand here”. Personal items and furniture were brought into the home by residents to personalise their rooms. Residents confirmed that they maintained links with their family and friends and that they could visit “at anytime”. The five questionnaires returned by residents identified the meals were always or usually good. Comments by residents about the meals at the home included “food very good and always a choice”, “food is perfect”, “good”, “meals are lovely – especially fish and chips” and “too much – I’m getting fat”. The menu for each meal was displayed in the dining room after the previous meal had finished. The meal advertised for lunch on the day was chicken pie, sautéed potatoes, green beans and carrots with pears and ice cream for desert. The breakfast and lunchtime meal was observed with plenty of attention being provided by staff. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 16 & 18 were inspected. Residents were confident their complaints would be listened to and acted upon. The recruitment processes, and staff understanding about what to do if they felt a service user was being put at risk of harm, were not sufficient to safeguard the residents’ safety and welfare. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The complaints procedure ensured that residents and/or their advocates were aware of how to make a complaint and who would deal with them. Residents stated that they were satisfied with the care provided and that they didn’t have any complaints. All residents’ questionnaires that were returned identified residents knew how to complain and who to speak to if they weren’t happy. They said if they had any complaints “he (Steve) will put things right”, “nephew visits regularly and would help sort any problems out if necessary” and “if there was something wrong I could go to Steve”. The pre-inspection questionnaire identified no complaints had been made and this was confirmed by the complaints record. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 Page 16 The manager confirmed they had obtained a copy of the local multi agency procedures for adult protection. The training matrix identified all staff had, had training on the protection of vulnerable adults but discussions with staff identified they were not clear of who they must report abuse to if it was someone in a more senior position than themselves. The recruitment process did not demonstrate staff were appropriately checked against the ‘Protection of Vulnerable Adults Register’. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 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 the following standard(s): The outcomes for standards 19, 24 & 26 were inspected. The building and its environment was clean and on the whole well-maintained, but there were aspects of the environment where housekeeping arrangements needed to improve to provide a safe environment for residents to live. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 Page 18 EVIDENCE: The atmosphere in the home was lively with music playing and residents and staff laughing and chatting. Residents had access to all indoor and outdoor facilities. Residents’ comments of their home included “bedroom very comfortable”, “couldn’t be better”, “so comfortable”, “it’s home from home”, “change bed very often”, “night staff often change it again”. Since the last inspection decoration and refurbishment that had taken place included the installation of a new bath and hoist on the first floor, eighteen armchairs for the lounges, new curtains for all bedrooms, the redecoration and new carpets for eleven bedrooms and Venetian blinds replacing net curtains. In contrast, there was a bath that was still not draining the water properly. Inspection of the premise today confirmed potholes remained in the drive way, there were wobbly chairs in the dining room, an ash tray was full of cigarette ends in the conservatory, the outside seating area had a broken pot and clump of earth in the area and in a bathroom there was a protruding pipe. These posed a potential risk to the safety and welfare of residents and required attention. Laundry facilities were sited away from food preparation areas and a comment by a resident included “send clothes to laundry and they come back perfect”. Domestic staff described the routines they completed to maintain a clean environment. They confirmed they were provided with personal protective equipment and cleaning materials to complete their duties to a high standard. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 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): The outcomes for standards 27, 28, 29 & 30 were inspected. The numbers and skill mix of staff was sufficient to meet the needs of residents. Residents were not protected by the recruitment procedure operated by the home. There had been staff training to equip staff with the knowledge and skills for their roles within the home, but further training was required to reinforce this knowledge in regard to the protection of vulnerable adults and the action to take in the event of fire. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 Page 20 EVIDENCE: Comments about staff from the five questionnaires that were returned and spoken to on the day included “staff very friendly and caring”, “always staff available”, “can chat with manager or staff at any time”, “staff are like relatives”, “they are marvellous” and “they pay a lot of attention to the very ill people here”. A general practitioner’s comment about staff at the home included “kind staff who seem to know all their patients well”. Good relationships between staff and residents were evident. Residents stated that they were satisfied with the level of care they received and that staff knew how to care for them. Observation of staff responding to assistance as required was good, however, staff need to ensure that when residents are in bed they are able to reach the call system to call for assistance when required. The staff rota confirmed the required number of staff were on duty. There was sufficient ancillary staff employed. The pre-inspection questionnaire identified sixty per cent of care staff were qualified to at least NVQ Level 2 or equivalent and ten staff held a First Aid Certificate. Discussions with staff identified they had, had some training. The training matrix confirmed this, as did the copies of certificates on file. Discussions with staff demonstrated their knowledge was not secure in the procedure to be followed should an allegation of abuse be made or if there was a fire at the home. This may place residents at risk of harm. After the last inspection the owner, Mr Shipley, made a complaint to the CSCI that “throughout the two year period when CRB checks were introduced at no time during inspections was it made clear that enhanced checks would be required for staff”. The complaint was not upheld and it was evidenced and reiterated to Mr Shipley that all staff working with service users must have an enhanced CRB check carried out. It was agreed that these could be carried out on a phased basis but must be completed by 9 August 2006. Two new staff files were inspected on a sample basis. They again did not demonstrate a CRB had been applied for and that a POVA first check had been completed prior to the staff commencing work. This was discussed with Mr Shipley subsequent to the inspection. Mr Shipley said he didn’t like keeping things like that at the home. I explained it was irrelevant of our personal views and that a thorough recruitment must be demonstrated as required by the regulations when I visit – how he did this was his decision. He said he would copy the top part of the form. I explained this would not be satisfactory, as it would not inform me whether the check was satisfactory or not. During the conversation Mr Shipley confirmed the enhanced CRB checks for all staff have been applied for and he has confirmed this by fax but will respond in writing to CSCI’s response in regard to his complaint. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 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): The outcomes for standards 31, 33, 35, 36 & 38 were inspected. Residents were highly satisfied with the management of the home. The home was run in the best interests of the residents. Residents’ financial interests on the whole were sufficiently safeguarded, but the description of where monies are received from and returned to and why were ambiguous and the manager needed to audit the records to identify an error. Staff were appropriately supervised. The health, safety and welfare of residents and staff were not sufficiently protected as the recruitment of staff was not sufficiently robust and staff needed further training in fire and the protection of vulnerable adults. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 Page 22 EVIDENCE: The manager was a qualified nurse and had approximately 17 years experience in residential management. Residents and general practitioners spoke highly of the management and staff team. Comments included “perfect - couldn’t get a nicer person”, “he will put things right”, “can chat with manager or staff at any time”, “he will tell you straight but kindly”, “manager’s as daft as a brush”, “if there was something wrong I could go to Steve (manager)” and “he’s a grand lad” and “kind staff who seem to know all their patients well”. The latest quality assurance survey was submitted. In summary, feedback was on the whole positive, complimentary and all those surveyed expressed satisfaction with the service. It identified action taken to resolve any problems and changes for the future. Visits to the home as required by the owner to demonstrate their opinions of the quality of the service provided were not being completed and a copy sent to the CSCI. Residents’ were able to maintain control over their finances if they wished and had the capacity to do so. The manager said personal allowances were paid to residents on a weekly basis. These transactions for two residents’ were inspected. Written records of all transactions were maintained. The record of monies held on behalf of a resident was maintained but in one instance the balance did not correlate with the monies held. The description of where the monies came ‘in’ and ‘out’ from was ambiguous and needed more detail. There were safe facilities to store the monies. One resident confirmed this saying “the manager will put money in safe”. A system for staff supervision was in place. Supervisions were held and documented and the record of supervision included what items had been discussed and what action was to be taken to develop staff practice. Hazardous substances were securely stored. Inspection of the building identified fire exits were free from obstructions. The fire drill matrix identified staff had been present on drills. The manager said fire training was done inhouse. Discussions with staff demonstrated their knowledge was not secure in the procedure to be followed if there was a fire at the home. This may place residents at risk of harm. The sluice areas were locked but could still be opened which could place residents at risk. The manager was asked to risk assess this and take action as appropriate. Notifiable incidents were being reported as required by the regulations. Good moving and handling techniques were observed. There was sufficient equipment and aids and adaptations provided to meet the needs of the residents, however, the maintenance of the hoist could not be demonstrated, therefore, that it was safe for residents to use could not be confirmed. The manager said the person who did the servicing had said the hoist was satisfactory but not issued a certificate. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 3 X 3 STAFFING Standard No Score 27 3 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 3 X 1 Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 Page 24 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. 2. Standard OP7 OP7 Regulation 15 15 Requirement The care plan must identify the action staff need to take to manage residents behaviour. The daily or behaviour record must accurately describe what behaviour the resident was displaying. All staff must receive training on the procedure to follow if an allegation of abuse is made, regardless of who the person is. The identified bath that is not draining must be repaired/replaced. Previous timescale of 30/11/05 & 31/03/06 not met. The driveway must be resurfaced. The wobbly chairs in the dining room must be repaired. Ash trays must be emptied on a regular basis. The broken pot and earth must be removed from the outside sitting area. The protruding pipe in the Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 Page 25 Timescale for action 23/05/06 23/05/06 3. OP18 OP28 OP30 OP19 13 & 18 30/09/06 4. 23 24/05/06 5. 6. OP19 OP38 OP19 OP38 23 23 31/12/06 24/05/06 7. 8. OP29 OP29 19 19 9. OP30 OP28 OP38 OP33 18 10. 26 11. OP35 12, 13 & 17 12. 13. OP38 OP38 13 13 bathroom must be made safe. Staff must not commence work until a POVA first check can be demonstrated. A thorough recruitment check as required by the regulations and standards must be made. Previous timescale of 30/06/05, 30/09/05 & 05/12/05 not met. Staff must receive fire training including the procedure to be followed in the event of a fire at the home. The registered owner must submit a report of the unannounced monthly visits to the home. Previous requirements of 31/10/05 & 28/02/06 not met. An audit of residents’ monies must be undertaken to identify the error where the identified residents’ monies did not correlate with the financial record. The security of sluice areas must be risk assessed and appropriate action taken. That the hoist is fit for purpose must be demonstrated. 23/05/06 09/08/06 31/07/06 31/07/06 26/05/06 09/08/06 23/05/06 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. Refer to Standard OP10 OP35 Good Practice Recommendations The manager should review in discussions with residents the types of aprons provided at meal times. The description of where the monies come ‘in’ and ‘out’ from must not be ambiguous. Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Park Grange DS0000018250.V294412.R02.S.doc Version 5.1 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!