Inspection on 08/11/05 for Park Grove

This inspection was carried out on 8th November 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 23/08/05

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 Pauline Randles Announced Inspection 8th November 2005 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 Grove DS0000005898.V249415.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 Grove DS0000005898.V249415.R01.S.doc Version 5.0 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 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) Mrs Una Banks Mr Kevin Michael Banks Mrs Judith Lemarinel Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23 August 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 DS0000005898.V249415.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over a six -hour period. There were twenty-five residents at home and one in hospital. The proprietor, manager, deputy manager, senior care staff, two care staff, a domestic assistant, the cook, a district nurse and five residents were spoken to. During the course of the inspection procedures and records were examined, lunch was taken with residents, activities were observed and the premises were viewed. Information from a pre inspection questionnaire and comment cards from a General Practitioner and a relative contributed to the findings. What the service does well: What has improved since the last inspection? A number of environmental improvements had taken place including completion of the installation of radiator guards, painting kitchen walls and a bathroom conversion. Quality of care planning processes had improved through greater involvement of residents and the introduction of falls risk assessments and nutritional assessments. The staff rota system had been developed so that it was clear who was on duty and in what capacity at any time of the day or night and whether they were trained in first aid. A complaints record had been established to ensure that any concerns expressed by residents were noted and acted upon. The staff recruitment and selection procedures had improved to ensure the suitability of potential employees to work in care services. Formal supervision of care staff had been introduced to provide guidance and support and assist individual development. Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 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 DS0000005898.V249415.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 Grove DS0000005898.V249415.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): 1 and 3 The Statement of Purpose and Service User Guide provides service users and their representatives with full details of the home’s services and facilities enabling an informed choice to be made about possible residency. EVIDENCE: The Statement of Purpose and Service User Guide met the requirements of the standard providing full details of services and facilities on offer at the care home. This level of detail enables a prospective resident to make an informed choice about future residence at Park Grove. When residents were asked whether the home had met their expectations comments made included, “I had heard before hand how good it is” and “ like home from home but it’s bigger.” Park Grove DS0000005898.V249415.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): 7, 8 and 9 Plans of care are detailed, reflecting assessed needs and providing staff with appropriate guidance on individual care service provision. The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. A full review of the written medication policy and procedures will ensure compliance with professional guidelines and direction for staff. EVIDENCE: Care planning systems had been improved as required following the previous inspection. Five resident’s files were examined that held risk assessments and nutritional assessments. Residents had signed their agreement to the care plan, daily diary sheets had been maintained and the care plans were being reviewed monthly ensuring a more effective and relevant service. Members of the care staff and residents spoken to confirmed their joint involvement in the process. A relative commented “ the care my mum receives is of a very high standard.” Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 10 Personal records of residents showed that appropriate health care had been accessed for individuals. This included optical, dental, chiropody, general practitioner and district nursing services. One General Practitioner had commented,” Have always found care staff caring and considerate, residents well cared for.” Two residents were bedfast at the time of inspection and being cared for in partnership with district nursing services. Rooms had been adapted to facilitate best care following risk assessments. Records examined, for example, a fluid intake chart, were fully and clearly completed. A district nurse visiting a resident at the time of inspection said, “ excellent care, follow up treatment is good, I would put Park Grove as one of my top three homes” The medication policy had been reviewed following the previous inspection. However, further development of the written policy and procedure was needed to ensure compliance with Royal Pharmaceutical Society guidelines. Medication storage and recording systems were viewed and found to be acceptable. A full review of medication systems was due to be undertaken the following day by the Pharmacy Inspector who will report back directly on her findings. Park Grove DS0000005898.V249415.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): 12,13 and 14 The appointment of a designated activities organiser has ensured that all residents will be involved in a wide range of individual and group activities that aid stimulation. Residents are enabled to see their chosen visitors in a safe and private environment. Personal support and services provided by the home ensure that residents are enabled to exercise choice and that independence is maintained. EVIDENCE: On the day of inspection a designated activities organiser had taken up post. A number of residents were observed to be involved in making greeting cards. The activities organiser had been issued with a book to record all activities provided and who had participated. The activities organiser confirmed her intent to consult with residents in regard to future activities and to check their satisfaction with activities that had taken place. This information would also be noted in the record book. It was acknowledged that individual and male orientated activities were equally important to ensure all needs are met. Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 12 The visiting policy was clearly set out in the Statement of Purpose of the home. Discussion with staff members confirmed their understanding of the policy in regard to upholding the rights of the resident to choose whom they see and don’t see and to ensure security and privacy within the environment. One staff member said, “ I wouldn’t let strangers in, unless I had checked with the resident.” Residents spoken to, confirmed that their visitors are always made welcome and a relative commented, “Staff are always cheerful and welcoming.” Residents, who were able, handled their own financial affairs. Information relating to advocacy was clearly displayed in the hallway of the home. Rooms viewed held personal possessions. When asked about being enabled to make choices residents confirmed meals and bedtimes were flexible. One resident said she had been encouraged to choose a later bedtime to combat some difficulties she’d had in getting to sleep. Residents had accessed personal records through their involvement in the care planning process. Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 13 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): 16 and 18 There are systems in place to enable residents to make complaints but the procedure does not fully inform residents of their rights within the process. Adult protection procedures had been extended to improve the safety and security of residents. EVIDENCE: As previously required a complaints log had been established, in which, a recent complaint from a relative had been recorded. To maintain confidentiality the detail of the complaint and the outcome had been noted on the resident’s file. Staff confirmed that they had an understanding of the complaints procedure and their role within it. Residents said they felt able to approach management with any issues. Comments made by residents when asked whether they had any complaints included “very content, couldn’t be better,” and “we’re short of nothing.” Residents were still unaware that the Commission for Social Care Inspection can be contacted at any stage of the complaints process. The request to extend the policy therefore remains a recommendation. The procedure for dealing with verbal or physical aggression had been reviewed as previously requested. Staff members were able to demonstrate an understanding of a suitable response if a resident became angry. One staff member said, “When someone shouts at you, you keep your calm.” A record had been kept on the diary sheet of any incidents arising. Senior staff Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 14 members were involved in any resulting risk assessment process. The manager was unable to locate a copy of the Department of Health, No Secrets guidelines at this inspection. Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 15 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): 25 and 26 The environmental standards are good providing residents with a clean and hygienic home in which to live. EVIDENCE: The remaining radiators had been covered to safeguard residents from the risk of scalding. Emergency lighting, call system and electrical wiring tests had been carried out to ensure the safe working order of these facilities. Building maintenance needs had been recorded and dealt with by a designated member of staff. When asked about safety and security residents confirmed that they felt safe, one resident said, “ there are a couple of guys here, who know all about electrics and house building.” The premises were clean and odour free at the time of inspection. Material and equipment suitable for the cleaning task had been provided and there was a secure storage area for products that might be hazardous to health with risk assessments undertaken and reviewed. A domestic assistant spoken to said, “whatever we need we just ask and its there.” Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 16 The premises had not been inspected in regard to the Water Supply (Water Fittings) Regulations 1999 to confirm safe fitting of facilities and this therefore remains a recommendation. Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 17 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): 27, 29 and 30 Staffing numbers are sufficient to meet the residents’ needs. The procedures for the recruitment of staff are adequate and safeguard residents. Training opportunities that enable staff to develop knowledge and skills relevant to their role are provided. EVIDENCE: The staffing rota had been developed as previously required to provide information about staff on duty at any time of the day or night and in what capacity. The rota also indicated which staff had undertaken first aid training. The home was staffed in accordance with regulatory requirements and adequately met the presenting needs of current residents. Procedures for recruitment and selection had improved since the last inspection. Two personnel files examined held all relevant documentation including two references and Criminal Records Bureau clearances that had been received prior to the commencement of work. A checklist had been developed to ensure that all documentation was in place for all employees. Staff members had been issued with job descriptions and terms and conditions of employment, a copy of which was held on the personnel file. Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 18 Evidence was seen that staff had undertaken recent training in the administration of medication, adult protection and fire training. Over 50 of care staff hold a National Vocational Qualification in Care at Level 2. Two recently appointed staff had completed first aid and moving and handling training. Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 19 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): 33, 35, 36 and 38 The culture of openness within the home and the use of formal quality assurance systems enable and encourage feedback as to how well the service is doing in meeting the needs of residents. The financial interests of residents are safeguarded by the policy and procedures of the care home. Improvements have been made to the supervision process to ensure relevant guidance and support is provided formally to care staff to enable their continuing competence The health and welfare of people living and working at Park Grove is assured through safe working practices. EVIDENCE: Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 20 Records showed that an independent quality assurance assessment had been conducted that resulted in the home being accredited as a five star care home. The proprietors had also undertaken a quality assessment, analysed the results and taken follow up action. The activities organiser appointment was an outcome of the consultation. Small amounts of money were held on behalf of those residents who lacked the capacity to handle their own finances. The funds were held securely and individually on behalf of residents. A written record of all transactions for each resident had been maintained. Supervision processes had been established since the previous inspection. Records examined indicated that care staff had received a recent supervision that generally covered all relevant matters. Procedures are being further developed to ensure regular supervision that specifically covers all areas as outlined in the standards. Training records evidenced that staff members had participated in training relating to safe working practices that had included fire safety, first aid and moving and handling. Infection control procedures were available. The proprietor was advised how to access the most recent infection control guidelines. Risk assessments in relation to the control of substances hazardous to health were examined. A domestic assistant when spoken to demonstrated an understanding of the importance of safe and secure use of hazardous substances. Safe working practices are covered during induction of new staff as noted from personnel files examined. Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 21 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 3 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X X X X 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 3 X 3 Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 22 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 OP9 Regulation 13 (2) Timescale for action The registered person must 31/12/05 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. (Previous timescale of 31/10/05 not met) Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP16 OP18 Good Practice Recommendations The complaints procedure should be revised to make clear that complainants may contact the Commission for Social Care Inspection at any stage of the process. A copy of Department of Health guidelines No Secrets should be held on the premises and be available for reference. Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley 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. Extracts may not be used or reproduced without the express permission of CSCI Park Grove DS0000005898.V249415.R01.S.doc Version 5.0 Page 24 - 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!