Inspection on 05/12/05 for Park Grange

This inspection was carried out on 5th December 2005.

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 23/05/06

Park Grange 01/07/05

Park Grange 17/03/05

Park Grange 25/06/04

Park Grange 26/03/04

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Hawkhills

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Beeches The - North Yorkshire County Council

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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 5th December 2005 08:30 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.V270903.R01.S.doc Version 5.0 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.V270903.R01.S.doc Version 5.0 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) 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.V270903.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st July 2005 Brief Description of the Service: Park Grange is a care home providing personal care and accommodation for 36 older people. Park Care Limited own the home. 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 Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over six hours from 8:30 to 14:30. Opportunity was taken to make a partial inspection of the premises, inspect a sample of records, observe care practices and talk to residents, staff and the manager. The majority of residents and staff were seen during the inspection and the inspector spoke in more detail to five of the staff on duty about their knowledge, skills and experiences of working at the home and seven residents about their views on aspects of living at the home. What the service does well: What has improved since the last inspection? What they could do better: To remove potential risks to residents’ safety, creams to be self-administered by residents must be securely stored. Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 6 The presentation in some areas of the home detracted from any improvements that had been made and on going maintenance of the building and surrounding grounds were required to provide a satisfactory, safe and clean living environment for residents. One area required urgent attention and this was dealt with on the day. Urgent action was issued regarding a member of staff, as a recruitment procedure had not been used to employ them and this did not protect the welfare of residents. An audit of staff training was required to ensure all staff were sufficiently trained to equip them with the knowledge and skills to complete their role in a competent manner and meet the needs of the residents’. Improvements were required with some of the records kept by the home to safeguard residents’ rights and best interests. Omissions and lack of details were noted in the home’s records, for example, the contract/terms and conditions, the care plan, medication records, recruitment, a formalised quality assurance system and supervision. Likewise the adult protection procedure needed updating to include current guidance on the subject. Urgent action was issued for the gas system and hoist to have up to date servicing and confirmation that the action required on the fixed electrical service has been addressed. 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.V270903.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was inspected. There was a resident who did not have a contract/terms and conditions with the home. EVIDENCE: Discussions with the manager and inspection of records identified there was a resident who was at the home without a contract/terms and conditions. The manager stated this was because the financial assessment to determine who would pay the fee had not been completed by the placing authority. Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 9 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 and 9 were inspected. Residents did have an individual plan of care, however, there were some omissions, lack of detail and incorrect information. Where residents were responsible for their medication, this was not identified in the medication administration record and was found insecurely stored in bedroom areas. EVIDENCE: One care plan was inspected on a sample basis. The plan did not clearly identify the resident had, had a previous stay at the home and that identified problems on previous stays had been reviewed and were still up to date and accurate. The plan contained some comprehensive information but there were some omissions, some information lacked detail and some details were incorrect. These included how the nutritional and medical needs of the resident were being met, supplements identified that were not required or prescribed and the property details of the resident not being up to date. A nutritional risk assessment was not in place. The daily report identified ‘creams applied’. This was not identified in the plan of care or what they were. The detail in the plan was supported by associated documentation including risk assessments. Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 10 The medication record of one resident was inspected on a sample basis. Medicines received in the home were recorded. Medicines retained by the home for administration were securely stored within the treatment room. Where residents were responsible for their medication, this was not identified in the medication administration record and was found insecurely stored in bedroom areas. The recording method for administration of creams did not identify the signature of the person who had administered the cream. Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 11 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): See below EVIDENCE: Outcomes for this section of the report were checked on the last inspection. Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 12 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 and 18 were inspected. The complaints procedure was clear. Residents did not have any complaints and no complaints had been recorded in the complaints record. The adult protection procedure needed updating and staff needed training to increase their knowledge of protection of vulnerable adults. 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. They said if they had any complaints they would tell Steve (the manager) or one of the staff because they’re “marvellous”. The adult protection procedure was out of date and did not include reference to current guidance on the subject. A copy of the local multi agency procedures was not in place. The manager was given contact details to obtain that information and advised that they also provided some training on the subject. Staff members said they would report any allegation of abuse to the appropriate person; however, those spoken with had not attended any formal training on the protection of vulnerable adults. Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 13 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 and 26 were inspected. The residents felt a comfortable standard of accommodation was provided. There had been some improvements to the environment of the home, however, the presentation in some areas of the home detracted from any improvements that had been made. On going maintenance of the building and surrounding grounds were required to provide a satisfactory, safe and clean living environment for residents. Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 14 EVIDENCE: Residents were satisfied with their living environment. Residents’ comments about their home included “lovely – we’ve just had our rooms redecorated with a new carpet and curtains”. Residents had access to all indoor and outdoor facilities. There were some bedrooms accessed by steps. Previous inspections had identified these would only be occupied by residents who did not have mobility problems. There was sufficient equipment and aids and adaptations provided to meet the needs of the residents, however, the maintenance of this equipment had not been kept up to date. Since the last inspection some decoration and refurbishment had been carried out including the dining room carpet and some corridor areas. Some previous requirements in regard to the environment have been carried forward. Inspection of the premise today identified potholes in the driveway, a showerhead and bath hoist that was engrained with dirt and mildew, a fitting to the light above the sink area in a bathroom missing, a bath not draining water properly, a pad left on a bathroom floor, skin sanitiser and toiletries and brushes left out in a bathroom, sluice areas left unlocked and a bedroom area that had a strong odour of urine. The showerhead and hoist required urgent attention. The deputy manager confirmed the action to clean the showerhead had been completed. Laundry facilities were sited away from food preparation areas. Inspection of the site noted new flooring had been provided so the floor area was easier to keep clean and thus control the spread of infection. Care staff and the laundress spoken with identified systems were in place to deal with laundry that controlled the spread of infection. Hand washing facilities were available. Information submitted to CSCI did not confirm the homes water systems met water supply regulations. Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 15 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 and 30 were inspected. The home could not demonstrate a recruitment procedure was used when employing a member of staff. This did not protect the welfare of residents. Not all staff had, had formal recognised training to equip them with the knowledge and skills to complete their role in a competent manner and meet the needs of the residents. EVIDENCE: The recruitment file for one member of staff was requested. There was no information available for the member of staff. This did not demonstrate that the recruitment process was sufficient to protect the welfare of residents who lived at the home and an immediate requirement was issued that instructed the home, the carer must not work on shift until evidence can be provided of a full recruitment check, including a POVA first check and subsequently a full and satisfactory CRB. The member of staff was 17 years old and had previously worked at the home whilst on a placement from a training agency. The manager stated fifty per cent of staff were trained to at least NVQ Level 2 in Care and all staff had attended moving and handling and an up date had been arranged. Discussions with staff identified they had, had no formal mandatory training, including, health and safety, moving and handling, fire, first aid, food hygiene and infection control or training that they had undertaken needed renewing. Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 16 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, 37 & 38 were inspected. Residents were highly satisfied with the management of the home. There was no evidence of a formalised quality assurance system in place that sought the views of residents and other stakeholders on the quality of care provided. Residents’ financial interests were safeguarded. Improvements were required with some of the records kept by the home to safeguard residents’ rights and best interests. The record for supervision did not demonstrate staff were appropriately supervised. The health, safety and welfare of residents and staff were not sufficiently protected as creams to be self administered were insecurely stored, recruitment of staff was not sufficiently robust, all staff had not had mandatory training or the training needed updating, the gas system and hoist required up to date servicing and confirmation of the action taken to address the requirements on the fixed electrical service was required. Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 17 EVIDENCE: The manager was a qualified nurse and had approximately 16 years experience in residential management. He did not hold NVQ level 4 in Management. Residents spoke highly of the management and staff team. There was no evidence of a formalised quality assurance system in place that sought the views of residents and other stakeholders on the quality of care provided. Residents that were spoken with were all satisfied with the service provided. Regulation 26 visits as required by the owner to demonstrate their findings 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 with the balance and monies correlating and signatures of two persons. The description of where the monies came ‘in’ and ‘out’ from was more prescriptive on this visit. There were safe facilities to store the monies. A sample of the records that the home was required to keep were inspected. These have been commented upon throughout the report and where necessary requirements made. Records were securely stored. A system for staff supervision was in place. Supervisions did not always take place at the required frequency. The record of supervision was inadequate, as it did not describe what was discussed and any outcomes or actions to be taken as a result, thus not demonstrating development of staff that should reflect in improvements in care practice. Hazardous substances were found insecurely stored. All staff had not participated in fire training/drill at the required frequency, which could mean residents are not in safe hands should a fire arise. Weekly and monthly checks of the fire alarm, emergency lighting and fire fighting equipment were in place. Fire extinguishers displayed evidence of servicing. No fire exits were blocked. The servicing of fixed electrical circuits identified the overall assessment as unsatisfactory and 15 items required urgent attention and the servicing for the gas and hoist was out of date. An immediate requirement was issued for urgent action to address these issues, as previous requirements made to address the issues had not been actioned. The home’s procedure for securing sluicing areas were not followed as sluicing areas were found unlocked. Risk assessments were in place for the risk of legionella and water temperatures were checked and a record maintained. Notifiable incidents were not being reported as required by the regulations. Also please see outcome for standard 9, medication practices, 19, environment and 29 recruitment practices. Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 18 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 1 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 1 1 Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 19 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 OP2 Regulation 5 & 17 Requirement All residents must have a contract/terms and conditions in respect of accommodation, services and facilities to be provided, including the fee to be paid. If on moving into the home, who is responsible for paying the fee has not been determined, this must be identified in the terms and conditions, including how the fee will be paid until that has been determined. Care plans must reflect the care provided and include nutritional risk assessments. The daily report must contain sufficient detail and correlate to the care identified in the plan. Where residents are responsible for their medication this must be identified as part of a risk management framework and include the storage of that medication. All medication must be safely stored. The medication record must include the signature of the DS0000018250.V270903.R01.S.doc Timescale for action 28/02/06 2. OP7 15 28/02/06 2. OP9 13 31/12/05 3. 4. OP9 OP38 OP9 13 13 31/12/05 28/02/06 Park Grange Version 5.0 Page 20 5. 6. OP19 OP19 23 16 & 23 7. OP19 23 8. 9. OP19 OP19 16 23 10. OP24 12 11. OP29 19 12. OP30 18 13. OP33 26 14. OP33 24 15. 16. OP36 OP38 18 23 person administering the medication. All parts of the home must be clean. An audit of all rooms must be undertaken and where repairs to facilities are identified these must be rectified. The identified bath must be repaired/replaced. Previous requirement of 30/11/05 not met. All areas of the home must be kept free from offensive odours. Toiletries must be appropriately stored. Individual brushes and combs must be used for each resident. The hasp and padlock type locks on service users furniture must be replaced. Previous timescales of 30/06/05 & 30/09/05 not met. A thorough recruitment check as required by the regulations and standards must be made. Previous timescale of 30/06/05 & 30/09/05 not met. The mandatory training of all staff must be audited and provided/updated where required. The registered owner must submit a report of the unannounced monthly visits to the home. Previous requirements of 31/10/05 not met. A quality assurance system must be demonstrated, including the views of the residents and advocates of the service provided. Staff supervision must take place at the required frequency. All staff must receive fire training/drills at the required DS0000018250.V270903.R01.S.doc 31/12/05 28/02/06 31/03/06 28/02/06 28/02/06 28/02/06 05/12/05 28/02/06 28/02/06 28/02/06 31/03/06 28/02/06 Park Grange Version 5.0 Page 21 17. OP38 13 18. OP38 13 19. 20. 38 38 13 37 intervals. Previous timescale of 31/10/05 not met. Confirmation is required that work identified as requiring urgent attention on the fixed electrical service has been completed. Previous timescale of 31/10/05 not met. Servicing of the gas systems and hoist must be undertaken. Previous timescale of 31/10/05 not met. All hazardous substances must be securely stored. All notifiable incidents must be reported as required by the Regulations. 06/12/05 05/01/06 31/12/05 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP26 OP27 OP36 Good Practice Recommendations The manager should provide evidence that the home complies with the Water Supply (Water Fittings) Regulations 1999. All members of staff should be 18 years of age. That the supervision record details the areas discussed in detail and any outcomes or actions to be taken as a result of the supervision. Park Grange DS0000018250.V270903.R01.S.doc Version 5.0 Page 22 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.V270903.R01.S.doc Version 5.0 Page 23 - 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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