Inspection on 26/01/07 for Park Grange

This inspection was carried out on 26th January 2007.

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

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

Other inspections for this house

Park Grange 20/02/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Park Grange Neville Avenue Kendray Barnsley South Yorkshire S70 3HF Lead Inspector Mrs Jayne White Key Announced Inspection 26th January 2007 09:30 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.V325084.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.V325084.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 none none None Park Care Limited 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) 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.V325084.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2006 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. 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 residents and prospective residents were on display in the entrance hall. The current scale of charges is £327.50. Additional charges are made for chiropody - £7.00, hairdressing – from £4.50 & day trips and outings – the donation dependant on the destination. This fee was that applied at the time of inspection and people may wish to obtain more up to date information from the care home. Park Grange DS0000018250.V325084.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key announced inspection that took place on 26 January 2007 for six hours from 9:30 to 15:30. Two inspectors, Jayne White and Sue Stephens, undertook the inspection. As part of the inspection process ten questionnaires were sent to residents to obtain their opinions on aspects of living at the home. Eight were returned. Three questionnaires were also sent to GPs to obtain their opinions of the home and all were returned. The inspection process included a partial inspection of the premises, inspecting a sample of records, observing care practices and talking to residents, staff, the manager and the owner. The inspector spoke in detail to four 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 resident 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 and staff benefited from the ethos, leadership and management approach at the home and residents were highly satisfied with the management and staff. The home was run in the best interests of the residents, with quality assurance systems in place. 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 who moved into the home, had, had their personal and health care needs assessed and were provided with access to health care services to promote and maintain their health care needs. Residents had an individual plan of care that had been formulated from this assessment of need. All residents that were spoken with and who returned questionnaires said their needs were met and they were happy with the care offered to them. Their comments Park Grange DS0000018250.V325084.R01.S.doc Version 5.2 Page 6 included “we are all well looked after”, “the staff are caring and helpful and go out of their way to try and make things homely”, “I have been medically very well looked after. Perhaps my blood pressure could be checked from time to time to be sure my medication is still appropriate”, “staff treat me well”, “always get a doctor when I need one”, “grateful for being here”, “care staff always there for me”, “they are sometimes busy but I’m not the only one here am I so they come when they can” and “can see my doctor when I want, get my eyes and feet done regular”. A GP commented, “they seem to provide decent standard of care”. If they did have any complaints residents were confident their complaints would be listened to and acted upon and said “Steve is always here if you need him”, “I would see Steve”, “I feel confident that I could speak to any member of staff, particularly the seniors and management”, “I’d speak to one of the carers or Steve”, “I’d speak to Steve or Sue”, “I go to any of the staff if I’m not happy and they sort things for me. If I need anybody I just pull the bell”, “I’d speak to Steve or Tom”, “I speak to Tom or Susan or Steve”, “never had to complain, they’ve been good to me here”, I’d go straight to seniors, they’d do something”, “I can honestly say there is nothing to complain about”, “I’d see Steve, he is marvellous. He will do something about it. He will be firm and sort it out straight away” and “it tells you on the board (how to complain)”. A GP commented they had no concerns. Residents were protected by the home’s policies and procedures for dealing with medicines. Residents said they were treated with respect and dignity. 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 “we have lots of games and sing-a-longs. I have been on trips to Cleethorpes and Blackpool”, “I really enjoy the activities and the effort that goes into them from the staff”, “I enjoy taking part in all the activities, especially trips and sing-a-longs”, “always things happening, I don’t always join in”, “if there’s anything I don’t like I just watch”, “like a game of dominoes, prefer to go to the pub for a pint daily”, “sometimes I’m not bothered”, “there’s always something happening”, “sometimes more bingo would be good but not many want to play. I like my crosswords. If you have nothing to do you get drowsy – that’s not good”, “it’s very sociable here. I knit, read and crochet”, “we have darts, bingo, dominoes and sometimes we have a singing session in the conservatory. There are trips if I want to go” and “sometimes not enough conversation. I like to talk”. Relatives and friends of residents were encouraged to visit the home and received a warm welcome. Residents received a diet that satisfied their requirements in a pleasant dining area. Comments included “the food is beautiful and always plenty of it”, “the new cooks have improved the meals recently”, “I always get something I like if I don’t want what’s on the menu”, “don’t like fish, but always give me something else, always get what I ask for”, “there’s nothing I dislike”, “very, Park Grange DS0000018250.V325084.R01.S.doc Version 5.2 Page 7 very good, put weight on since I’ve been here which is good”, “I can’t grumble, there’s always something to eat even if I don’t like what’s on the menu”, “we pick what we want and if we want something different we can have it” and “generally good, yes, if you don’t like it they will give you something else”. 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. Comments by residents about staff who worked at the home included “there’s always someone about to help me”, “I’m very happy here. All the staff are very nice and friendly and take good care of me”, “sometimes they are busy but they always come as soon as they can”, “if I ask someone to do it for me”, “they’ve always been there when I’ve asked for owt”, “when they have time, they will help if it’s possible. They see to a lot of little things you mention”, “I’ve found so. If you mention that you want something they will oblige you”, “can’t do enough for me”, “they always do for me”, “there all the time”, “staff are alright – they talk to you alright”, “brilliant”, “staff are very good” and “nothing’s too much trouble, my carer does my room and gets me what I want”. Residents’ financial interests were sufficiently safeguarded. The health, safety and welfare of residents and staff was promoted and protected. What has improved since the last inspection? Staff had received training on the procedure to follow should an allegation of abuse be made. The policy/procedure for the protection of vulnerable adults had been reviewed and now included reference to Public Information Disclosure Act (Whistleblowing) and No Secrets. In addition, it now included the action to be taken should an allegation of abuse be made including the suspension of the member of staff to protect both the vulnerable person and the staff member and pending the outcome of the investigation, that the staff will be referred to the provisional protection of vulnerable adults register (as per POVA guidance). Inspection of the premise today confirmed previous risks to the safety and welfare of residents had been dealt with and the environment was tidy, clean and fresh. This included the repair of the bath that was not draining properly, repairing wobbly chairs in the dining room, emptying ash trays on a regular basis, removing a broken pot and earth from the outside sitting area and placing a ‘rubber’ on the protruding pipe in the bathroom so that it reduced the risk of a resident hurting themselves if they caught themselves on it. Park Grange DS0000018250.V325084.R01.S.doc Version 5.2 Page 8 Police checks were now securely stored at the care home so they can be checked at the next inspection and staff working at the home now had enhanced police checks including a check against the protection of vulnerable adults register. Staff had received fire training including the procedure to be followed in the event of a fire at the home. 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.V325084.R01.S.doc Version 5.2 Page 9 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.V325084.R01.S.doc Version 5.2 Page 10 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 home did not provide an intermediate care service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had not moved into the home without having had their needs assessed. EVIDENCE: The inspection of the two residents’ records identified a basic assessment of need when the residents had moved into the home had been completed. Park Grange DS0000018250.V325084.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents did have an individual plan of care, but the daily report would benefit from more detail. 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. EVIDENCE: Two individual plans of care were inspected on a sample basis. The plans contained good profile information, records of medical treatment and risk Park Grange DS0000018250.V325084.R01.S.doc Version 5.2 Page 12 assessments of falls, moving and handling and nutrition. The record indicated reviews were held. The daily reports contained only basic detail to describe the action taken by staff to meet the residents personal, health and social care needs. For instance, diet and fluids taken well but not what this meant, for example, drank a cup of tea and ate a poached egg on toast for breakfast and therefore could be improved. All residents spoken with were pleased with the care they received. Of the eight questionnaires returned, seven said they always receive the care and support they need; one usually. All said they always received the medical support they needed. Comments by residents about the care provided included “we are all well looked after”, “the staff are caring and helpful and go out of their way to try and make things homely”, “I have been medically very well looked after. Perhaps my blood pressure could be checked from time to time to be sure my medication is still appropriate”, “staff treat me well”, “always get a doctor when I need one”, “grateful for being here”, “care staff always there for me”, “they are sometimes busy but I’m not the only one here am I so they come when they can” and “can see my doctor when I want, get my eyes and feet done regular”. A GP commented, “they seem to provide decent standard of care”. Residents were happy with the way their medication was managed. A GP commented, “they tend to over order medications and stock pile”. Inspection of the medication demonstrated there was no surplus medication. In summary, the administration of medication and associated records demonstrated good clear records were in place with countersignatories for controlled medication and a stock balance, assessment form for residents who self-administered some of their own medication with a review date identified and records demonstrated countersignatories when a handwritten entry was made onto the medication administration record. The fridge and medication trolley used for storage were clean and tidy and temperature records of the fridge were maintained. All residents spoken with said that they were well cared for, staff treated them with respect and they were able to spend time in their room if they wished. 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. Park Grange DS0000018250.V325084.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. Relatives and friends of residents were encouraged to visit the home and received a warm welcome. Residents received a diet that satisfied their requirements in a pleasant dining area. EVIDENCE: Of the eight questionnaires completed by residents said the home, five said the home always arranged appropriate activities that they could take part in; three usually. Their comments included “we have lots of games and sing-a-longs. I have been on trips to Cleethorpes and Blackpool”, “I really enjoy the activities and the effort that goes into them from the staff”, “I enjoy taking part in all Park Grange DS0000018250.V325084.R01.S.doc Version 5.2 Page 14 the activities, especially trips and sing-a-longs”, “always things happening, I don’t always join in”, “if there’s anything I don’t like I just watch”, “like a game of dominoes, prefer to go to the pub for a pint daily”, “sometimes I’m not bothered” and “there’s always something happening”. 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 “sometimes more bingo would be good but not many want to play. I like my crosswords. If you have nothing to do you get drowsy – that’s not good”, “it’s very sociable here. I knit, read and crochet”, “we have darts, bingo, dominoes and sometimes we have a singing session in conservatory. There are trips if I want to go” and “sometimes not enough conversation. I like to talk”. Personal items and furniture were brought into the home by residents to personalise their rooms. Residents were observed receiving visitors throughout the day. Visitors spent time with their relatives/friends in communal areas and staff were welcoming and friendly to visitors. Residents confirmed that they maintained good links with their family and friends and that they could visit “at anytime”. Of the eight questionnaires returned by residents, six said they always like meals at the home; one usually and one sometimes. Comments by residents about the meals at the home included “the food is beautiful and always plenty of it”, “the new cooks have improved the meals recently”, “I always get something I like if I don’t want what’s on the menu”, “don’t like fish, but always give me something else, always get what I ask for”, “there’s nothing I dislike”, “very, very good, put weight on since I’ve been here which is good”, “I can’t grumble, there’s always something to eat even if I don’t like what’s on the menu”, “we pick what we want and if we want something different we can have it” and “generally good, yes, if you don’t like it they will give you something else”. 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 fish, chips and peas or poached fish and chocolate angel delight. Park Grange DS0000018250.V325084.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were confident their complaints would be listened to and acted upon. Policies and procedures to ensure appropriate responses are made by the manager and owner to ensure the safety and protection of residents should an allegation of abuse be made, have been reviewed and should now, if followed, be sufficient to safeguard residents from abuse. 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 “Steve is always here if you need him”, “I would see Steve”, “I feel confident that I could speak to any member of staff, particularly the seniors and management”, “I’d speak to one of the carers or Steve”, “I’d speak to Steve or Sue”, “I go to any of the staff if I’m not happy and they sort things for me. If I need anybody I just pull the bell”, “I’d speak to Steve or Tom”, “I speak to Tom or Susan or Steve”, “never had to complain, they’ve been good to me here”, I’d go straight to seniors, they’d do Park Grange DS0000018250.V325084.R01.S.doc Version 5.2 Page 16 something”, “I can honestly say there is nothing to complain about”, “I’d see Steve, he is marvellous. He will do something about it. He will be firm and sort it out straight away” and “it tells you on the board (how to complain)”. A GP commented they had no concerns. The pre-inspection questionnaire identified no complaints had been made and this was confirmed by the complaints record. A copy of the local multi agency procedures for adult protection was in place. The training matrix identified all staff had, had training on the protection of vulnerable adults and discussions with staff identified they were clear of who they must report abuse to. The policy and procedure available for protection of vulnerable adults had been reviewed and it included guidance of what is expected should they suspect or witness abuse. The procedure now included reference to local multi-agency procedures for the investigation methodology should an allegation of abuse be made. In addition, information on the Public Interest Disclosure Act 1998 and the Department of Health guidance No Secrets were now in place. The procedure had also been updated to include referral of staff to the provisional Protection of Vulnerable Adults Register when an allegation of abuse is made. It was reviewing the policy and procedure and being exposed to an allegation of abuse that had improved the manager’s knowledge and understanding of the process, including the purpose of the provisional and permanent register for the protection of vulnerable adults and the purpose of the register in regard to CRB checks. The manager or owner had not undertaken formal training in the protection of vulnerable adults. This is essential to clarify their updated knowledge particularly with local adult protection protocols and would be a valuable source of support should a further allegation be made. Park Grange DS0000018250.V325084.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offered a comfortable standard of accommodation and the living environment was well decorated, well maintained and clean. 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 “yes, it’s beautiful here”, “very high standards”, “a smashing home and I’m very happy here”, “very nice home”, “satisfies me”, “I haven’t found any muck or smells”, “got a lovely very big bedroom – big enough for my electric wheelchair and keyboard”, “I can honestly say it’s perfect here. I wouldn’t say if it wasn’t”, “it’s very good here – like Buckingham Palace” and “clean enough for me”. Park Grange DS0000018250.V325084.R01.S.doc Version 5.2 Page 18 A discussion took place with the owner of the home who was unwavering in his opinion that the surface of the driveway was safe enough for residents and staff, despite his own regulation 26 visit identifying it needed resurfacing. The inspector would disagree and therefore asked the manager to conduct a risk assessment in regard to the risks presented by the driveway and to take action to address any of the risks identified. Inspection of the premise today confirmed previous risks to the safety and welfare of residents had been dealt with and the environment was tidy, clean and fresh. Laundry facilities were sited away from food preparation areas. 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.V325084.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff was sufficient to meet the needs of residents. On the whole, residents were now protected by the recruitment procedure operated by the home. Staff said they were trained to equip them with the knowledge and skills for their roles within the home, to enable them to care for residents in a safe way, but documentary evidence of the training and qualifications were not on file. EVIDENCE: Comments about staff from the eight questionnaires that were returned and spoken to on the day included “there’s always someone about to help me”, “I’m very happy here. All the staff are very nice and friendly and take good care of me”, “sometimes they are busy but they always come as soon as they can”, “if I ask someone to do it for me”, “they’ve always been there when I’ve asked for owt”, “when they have time, they will help if it’s possible. They see to a lot of little things you mention”, “I’ve found so. If you mention that you want something they will oblige you”, “can’t do enough for me”, “they always Park Grange DS0000018250.V325084.R01.S.doc Version 5.2 Page 20 do for me”, “there all the time”, “staff are alright – they talk to you alright”, “brilliant”, “staff are very good” and “nothing’s too much trouble, my carer does my room and gets me what I want”. 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. The staff rota identified on the whole the required number of staff were on duty. There was sufficient ancillary staff employed. The pre-inspection questionnaire identified fifty seven per cent of care staff were qualified to at least NVQ Level 2 or equivalent and sixteen staff hold a First Aid Certificate. Discussions with staff identified they had, had some training. The training matrix identified the training completed and the training arranged, however, copies of qualifications and certificates of up to date training needs to be consistently in place on files to verify the authenticity of the training. Apart from one requirement, Mr Shipley had completed the requirements made of him in regard to CRB’s for staff working at the home. The requirement that had not been completed by Mr Shipley was because he stated there was evidence within the original standard police check that the members of staff were not placed on the protection of vulnerable adults register. This evidence had not been presented at the time of a meeting with senior managers at CSCI. As the members of staff have not worked elsewhere prior to an enhanced CRB being issued, CSCI have accepted the original protection of vulnerable adults register clearance on the standard police check, as this information had not been requested on the enhanced CRB. Three staff files were inspected to demonstrate the recruitment process. The files demonstrated application forms were completed; two references had been received and an enhanced CRB had been issued. The files did not demonstrate a full employment history, however, these were not recent appointments, but the manager was informed of this and that for any new employees it will be required that a full employment history must be in place, together with a satisfactory written explanation of any gaps in employment, if applicable. Park Grange DS0000018250.V325084.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff benefited from the ethos, leadership and management approach at the home and residents were highly satisfied with the management and staff. The home was run in the best interests of the residents, with quality assurance systems in place. Residents’ financial interests were sufficiently safeguarded. The health, safety and welfare of residents and staff was promoted and protected. Park Grange DS0000018250.V325084.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager was a qualified nurse and had approximately 18 years experience in residential management. Staff morale was good. Discussions with the manager demonstrated he was familiar with residents’ needs that enabled him to contribute to the care of residents. This was demonstrated by the fact that residents spoke highly of the manager and the staff team. Staff felt that there was good teamwork within the home and that they enjoyed working there. Several staff had worked at the home for many years, enabling them to provide a consistent service to residents. The quality assurance system facilitated a process whereby the views of residents 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. Visits to the home as required by the owner to demonstrate their opinions of the quality of the service provided were not consistently been completed with 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 transactions for two residents’ were inspected on a sample basis. Written records of all transactions were maintained. There were safe facilities to store the monies. Hazardous substances were securely stored. Inspection of the building identified fire exits were free from obstructions. Fire training and/or drills for staff were in place and a fire risk assessment was in place. Fire training was done in-house. On the whole discussions with staff confirmed they could verbally describe the procedure they would follow in the event of a fire. Notifiable incidents were being reported as required by the regulations. On the whole good moving and handling techniques were observed. There was sufficient equipment and aids and adaptations provided to meet the needs of the residents. The pre-inspection questionnaire identified maintenance and associated servicing of fire equipment, the environmental health, gas, central heating, water temperatures, fixed wiring and hoists and adaptations was in place. These were not all up to date. This was discussed with manager who confirmed they were now all up to date. Park Grange DS0000018250.V325084.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 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 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 3 Park Grange DS0000018250.V325084.R01.S.doc Version 5.2 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. Standard OP18 Regulation 13 & 10 Requirement The responsible individual, Mr Shipley and manager, Mr Chance must undertake training to respond appropriately to allegations of abuse. Previous timescale of 28/10/06 not met. The driveway must be resurfaced. Previous timescale of 31/12/06 not met. Conduct a risk assessment of the driveway and implement the action to be taken to eliminate any risks identified. The staff files must contain documentary evidence of qualifications and training. The recruitment process must demonstrate a full employment history, together with a satisfactory written explanation of any gaps in employment. Timescale for action 30/04/07 2. OP19 23 31/07/07 3. OP19 13 31/03/07 4. 5. OP28 OP30 OP29 19 19 31/03/07 31/03/07 Park Grange DS0000018250.V325084.R01.S.doc Version 5.2 Page 25 6. OP33 26 The registered owner must submit a report of the unannounced monthly visits to the home. Previous requirements of 31/10/05, 28/02/06 & 31/10/06 not met. 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Park Grange DS0000018250.V325084.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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.V325084.R01.S.doc Version 5.2 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!