Inspection on 23/08/05 for Park Grove

This inspection was carried out on 23rd August 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 Grove 07/01/09

Park Grove 17/01/07

Park Grove 08/11/05

Park Grove 22/02/05

Park Grove 25/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Park Grove 2-4 Liverpool Road North Burscough Ormskirk, Lancashire L40 7SA Lead Inspector Sue Hale Unannounced 23 August 2005 09:00 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 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 Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Park Grove Address 2-4 Liverpool Road North Burscough Ormskirk Lancashire L40 7SA 01704 893750 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Una Banks and Mr Kevin Michael Banks Mrs Judith Lemarinel Care Home 32 Category(ies) of OP - Old age registration, with number of places Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22 February 2005 Brief Description of the Service: Mr and Mrs Banks own Park Grove. The house, once a private residence, has been developed over the years to provide personal care and accommodation for up to 32 older people. The home is located in the small village of Burscough, near to shops, pubs and other village amenities. The home provides accommodation throughout two floors and currently single room accommodation is offered, although shared facilities can be made available. Accessible toilets and bathrooms are located on both floors near to bedroom and living rooms. The communal areas are situated on the ground floor and a passenger lift is available for access to the first floor. The home has ample garden space with garden furniture for the service users to enjoy. Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on one day in August 2005. The inspection involved discussion with the people who lived and worked at the home, examination of records, policies and procedures and a tour with the premises. As part of the inspection process the inspector used ‘case tracking ‘as a means of assessing some of the national minimum standards. This process allowed the inspector to focus on a small group of people living at the home. All records relating to these people were inspected, along with the rooms they occupied in the home. What the service does well: What has improved since the last inspection? The homes environment had significantly improved to provide a comfortable and homely place for residents to live. Several residents’ rooms and communal areas had been redecorated and refurbished; new carpets had been laid in all communal areas. Rails had been fitted in corridors and the majority of radiators were now covered. Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 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 standard(s) 3 The admission and assessment procedures were brief but clear to ensure the care needs of residents are met. EVIDENCE: An assessment of residents’ health, personal care and social needs had been carried out by social services and the home before residents came to live at the home. The assessments were factual, but lacked detail about residents specific care needs and how the home would be able to meet them. Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 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 standard(s) 7,8,9,10 The care planning process was not thorough enough to ensure that individual needs were consistently met. Residents had access to all relevant health and medical care. EVIDENCE: One of the three residents files checked did not have a care plan or other assessments and this was confirmed by staff as standard practice for residents admitted on a short-term basis. The care plans checked did not cover all the recommended topics and didnt give clear instructions to staff on how to meet residents’ needs. People living at the home had not been involved in drawing up their care plans or in reviewing their care needs. Entries had not been made on a daily basis on residents’ diary sheets, so that there wasn’t a continuous record of care given or significant events. Care plans had not been reviewed regularly to ensure that they reflected residents current care needs. People living at the home were comfortable and well cared for. They were appropriately dressed and attention had been paid to their personal hygiene needs and pressure area care. Specialised equipment for pressure care relief Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 Page 10 had been provided as required. Residents were encouraged and supported by staff to access health and medical care. Records relating to the administration of medication, and the way in which medication was stored were generally satisfactory, although the policy and procedure needed improving to reflect the guidelines of the Royal Pharmaceutical Society guidelines. People living at the home said that staff maintained their dignity and treated them respectfully. Residents had access to a telephone to use in private and their post was delivered to them opened. Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 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 standard(s) 15 The meals served in the home were of a high standard. EVIDENCE: Meals were seen to provide a wholesome balanced diet. The food served was fresh, of good quality and homemade. Mealtimes were seen to be unhurried, and support was given to residents requiring assistance. The menu was displayed in the hallway. The cook kept a record of all residents likes and dislikes ensuring that if they disliked what was on the menu that alternatives were always offered and available. A resident said that the food was’ good and that there was plenty of it’. Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 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 standard(s) 16,18 Staff were unaware of the correct procedure to follow in the event of a complaint being made. Arrangements to protect residents were not satisfactory, and didnt ensure the safety of residents. EVIDENCE: There was a complaints policy and procedure in the home and available for all to see on a notice board. It did not make clear that residents and their relatives/representatives were able to contact the Commission for Social Care Inspection at any stage of a complaint. Staff spoken to was unaware of where complaints should be recorded and a complaints book could not be found. A policy was available for protecting vulnerable adults from abuse, however, there was no clear definition of abuse or procedure for reporting and recording allegations, and it was not clear who had the responsibility for reporting incidents. Not all staff have had checks undertaken by the Criminal Records Bureau to ensure that they are fit to work at the home. All staff spoken to were aware of the whistle blowing policy and how to report any concerns about care practices in the home. The policy on how to manage verbal and physical aggression by residents did not give staff clear advice or instructions on how to defuse difficult situations. The financial policy did not make clear that staff should not assist residents in drawing up wills and that they should not accept gifts from residents to ensure the protection of residents. Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 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 standard(s) 19,25,26 Since the last inspection a refurbishment plan had been put in place, and there was evidence of improvements throughout the home, which had created a homely and comfortable place to the residents to live. EVIDENCE: Six residents rooms, three bathrooms the lounges and hallways had been decorated since the last inspection. All the carpeting in communal areas, including corridors had been replaced to improve the environment in which residents lived. Staff recorded any maintenance issues, and the handyman to ensure that residents lived in a safe and comfortable environment addressed these. The majority of the radiators had been covered and covers ordered for the remaining 10, which were scheduled to be completed in the near future. A visitor to the home said that they were’ always made welcome and the home was always clean’. There was no evidence that the premises conformed to the relevant water regulations. Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 Staffing numbers are sufficient to meet the residents’ needs. The procedures for the recruitment of staff are inadequate, and did not safeguard residents. EVIDENCE: A staff rota, written in pencil was available, but did not detail the capacity in which staff were employed and was not an accurate reflection of staff on duty on the day of the inspection. Staffing numbers were sufficient to meet the residents’ needs. Four new members of staff were working in the home. One staff file was not on the premises. The home had not undertaken the necessary checks including a POVA First and Criminal Records Bureau check. Staff files checked did not contain all the documentation required to ensure the protection of residents. Immediate requirements in relation to the employment of staff were given on the day of the inspection. Residents spoken to were very satisfied with staff who were described as ‘very kind’ and ‘always polite’. The home employed 14 care staff 50 of whom were qualified to NVQ level 2 or above, and a further two registered on an NVQ 2 course to ensure that the staff were skilled and experienced to provide the level of care the residents required. Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 Formal supervision of care staff did not take place. EVIDENCE: The homes supervision policy had not been followed and staff had not received formal supervision to ensure that they were providing the level of care required by the home. A supervision record that covered the topics recommended in the national minimum standards was not in place. Staff spoken to said they were given good support by the manager, deputy manager and owner and that advice and guidance was available, as required. Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 2 x STAFFING Standard No Score 27 2 28 3 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x 2 x x Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 Page 17 yes Are there any outstanding requirements from the last inspection? 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,schedu le 3(1)(b) 15 (1 )(2)(d) Requirement Timescale for action 30.09.05 3. OP7 13(4)(C) The registered person must ensure that all residents have a written plan of care. The registered person must 31.10.05 ensure that residents and their relatives/representatives are involved in the care planning and review process. The registered person must 30. 9.05 ensure that risk assessments in relation to falls are undertaken on admission and reviewed regularly thereafter. The registered person must 31.10.05 ensure that the medication policies and procedures are in line with Royal Pharmaceutical Society of Great Britain guidelines to cover all aspects of medicines management. The registered person must 31.10.05 ensure that all staff would administer medication are suitably qualified and competent. The registered person must 31.10.05 ensure all that the homes policy and procedure on protecting vulnerable adults is revised and reflects the Department of Healths guidance No Secrets. Version 1.40 4. 5. OP9 13(2) 6. OP 9 18 (1) (a) (c) (i) 13(6) 7. OP18 Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Page 18 8. OP18 9. OP16 10. 11. OP25 OP29 12. OP29 13. OP36 14. OP 36 The registered person must ensure that the policy and procedures in relation to physical and/or verbal aggression by residents is revised to include advice and instructions to staff on how to defuse difficult situations. 22 The registered person must schedule ensure that a complaints record 4 (11) is available and that staff are aware of the procedure and how to record complaints. 13(4)(a)(c The registered person must ) ensure the safety of residents by putting in place radiator guards. Schedule The registered person must 2 ensure that all documentation schedule required in the Care Home 4 (6) Regulations 2001 is obtained and a record kept on each staff file 19(1)(2) The registered person must ensure that staff do not work at the home, unless full and satisfactory information has been obtained via a POVA check and criminal records bureau check has been applied for. 18(2) The registered person must ensure that persons working at the care home are appropriately supervised. 18(1)(c)(i A registered person must ensure ) that persons undertaking supervision of other staff receive appropriate training. 13 (6- 8) 31.10.05 30.9.05 31.10.05 5.9.05 5.9.05 31.10.05 31.10.05 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. Refer to Standard OP3 Good Practice Recommendations It is recommended that the pre admission assessments include more detailed information about residents needs. F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 Page 19 Park Grove 2. 3. 4. 5. 6. 7. 8. 9. OP7 OP7 OP8 OP7 OP7 OP9 OP9 OP16 10. OP18 11. 12. 13. 14. 15. 16. 17. 18. 19. OP26 OP27 OP27 OP 27 OP 27 OP 29 OP 29 OP 36 OP 36 It is recommended that the care plan covers all topics detailed in standard 3.3. It is recommended that entries are made on a daily basis on the diary sheet for all residents detailing the care given and any significant events. Nutritional risk assessments should be undertaken on admission for all residents and reviewed regularly thereafter. It is recommended that the care plan form is revised to include space for the residents and/ or their relative/representative to sign their agreement. It is recommended that the care plans are reviewed monthly and updated as necessary. Manufacturers patient information leaflets should be available for all medicines in the custody of the home. It is recommended that the manager obtains written consent for the administration of medication from residents and/or their relatives or representatives. It is recommended that the complaints procedure is revised to make clear that complainants are able to contact the Commission for Social Care Inspection at any stage of the complaint if they so wish. The financial policy should make clear that staff are precluded from assisting in the making of all benefiting from residents wills. It should also make clear that staff should not accept gifts from residents. The registered person should ensure that the premises meet the Water Supply (Water Fittings) Regulations 1999. It is recommended that the staff rota is completed in ink. The staff rota should be an accurate reflection of staff on duty at any time in in the home. The staff rota should detail in what capacity staff are employed at the home. The staff rota should detail which members of staff are qualified in first aid. Consideration should be given to developing a checklist for staff files. Staff should be given copies of their job description and terms and conditions of employment. A supervision record that covers the topics recommended in standard 36.3 of the national minimum standards should be developed. Supervision should take place at least six times a year for all staff. Park Grove F57 F08 S5898 Park Grove V235922 230805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Levens House Ackhurst Business Park Foxhole Road Chorley, Lancashire, PR7 1NW 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. 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