Inspection on 15/11/05 for Park Hall Resource Centre

This inspection was carried out on 15th 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 Hall Resource Centre 28/10/08

Park Hall Resource Centre 03/10/06

Park Hall Resource Centre 14/06/05

Park Hall Resource Centre 22/11/04

Park Hall Resource Centre 22/01/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Park Hall 1 Park Hall Reigate Surrey RH2 9LH Lead Inspector Helen Dickens Unannounced Inspection 15th November 2005 09:45 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 Hall DS0000033528.V263475.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 Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Park Hall Address 1 Park Hall Reigate Surrey RH2 9LH 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) 01737 224420 01737 223755 sharon.woodings@surreycc.gov.uk South West Surrey Adults & Community Care Services Sharon Gina Woodings Care Home 50 Category(ies) of Dementia - over 65 years of age (26), Learning registration, with number disability over 65 years of age (1), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (6), Old age, not falling within any other category (30) Park Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Abbey Unit will be exclusively for the provision and/or Intermediate Care to a maximum of 10 Service Users. Accommodation and Services may be provided to named persons aged 60 - 65 years with prior written agreement of the NCSC. Respite Care may be provided to a maximum of 5 persons at any one time. These persons should be grouped into the same unit. Cloverdale (L&R) Unit will be used only by Service Users with Dementia. 6 Service Users with Dementia may be cared for in other parts of the Home. In addition to Service Users accommodated at the Home, Day Care may be provided on the Day Care Unit to a maximum of 20 persons. One named service user in the category LD (learning disability) may be accommodated on Brock Unit 14th June 2005 Date of last inspection Brief Description of the Service: Park Hall is located in a quiet residential area on the outskirts of Reigate; it is operated by Surrey County Council. Care and accommodation is provided for older people, some of who have dementia. Park Hall also provides intermediate care and rehabilitation on the Abbey Unit. The home is single storey and was purpose built in a modern design. Accommodation is arranged in five small units. Each unit has it’s own bathroom and toilet facilities, a kitchenette and a communal lounge/dining area. All bedrooms are single. Additional facilities include the day centre, offices, meeting rooms and kitchen. There are several ‘quiet’ areas for residents to sit, including a small library area. The home has ample off street parking and an enclosed garden. Park Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Helen Dickens, Lead Inspector for the service. Sharon Woodings, Registered Manager, represented the establishment. A tour of the premises took place and the inspector met most of the residents, and spoke to six residents in more depth. Two staff were spoken to and a number of documents and files examined as part of the inspection. Fewer Standards were assessed at this inspection as the majority of ‘key’ Standards were examined at the June inspection. This was a positive inspection. The inspector would like to thank the residents, staff and the Registered Manager at Park Hall for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? The home continues to improve on its success rate regarding the provision of intermediate care and currently 63 of those using this service return to independent living in the community. A number of improvements to the décor have taken place including a new carpet in the day centre. There is better access for disabled people including outside kerbs being lowered and more appropriate door handles being fitted. A parking bay has also been set aside for disabled parking only. A worn ramp has been replaced and external doors mended. A new patio has also been built since the last inspection. Recently a new call bell system has been fitted. Park Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 6 The chef said that the new cooker purchased for the main kitchen was very efficient and producing some good results. The number of in-house activities has increased recently and hiring a karaoke machine has proved to be very popular with residents and staff. Park Hall has also appointed a new deputy manager since the last inspection. 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 Hall DS0000033528.V263475.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 Hall DS0000033528.V263475.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): 6 Residents admitted for intermediate care are assisted to maximise their independence and return to independent living. EVIDENCE: On the day of the inspection Park Hall had three residents who were receiving rehabilitation and support to become independent and return home. There are also some respite and permanent residents on this wing but dedicated facilities and services are provided for those receiving rehabilitation. Each period of rehabilitation lasts for 2-6 weeks depending on the persons needs, and this is sometimes extended following a further assessment. Physiotherapists and occupational therapists, together with other members of the promoting independence (PIP) team, visit the home on a daily basis to support these residents and train and guide the Park Hall staff in rehabilitative techniques as appropriate. All residents on this programme have their own ‘skills gains’ goals and record of achievements, which is kept up to date by the unit staff and the PIP team. Park Hall DS0000033528.V263475.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, 9 and 11. Care plans clearly set out resident’s health and social care needs; this ensures staff will be able to care for them appropriately. The administration of medication is well organised at Park Hall though a few further improvements must be made to meet this Standard in full. Residents at Park Hall can be confident that, at the time of their death, they and their friends and family, will be treated with care and sensitivity. EVIDENCE: Care plans examined were well set out and reviewed regularly. Cultural needs were being fully assessed and met, particularly in regard to how residents like to receive personal care, and special religious and dietary requirements were well documented. One resident with special cultural needs confirmed that they were well cared for and happy at this home. Residents receiving rehabilitation had thorough assessments and clear records of their daily progress as they worked towards being independent and returning home. Medication is well organised at Park Hall and staff were knowledgeable about resident’s needs and the home’s policies. Good records were kept though a few gaps were found on the medication administration records and these needed to be followed up. Staff were observed to be dealing sensitively with residents who have dementia when giving them their medication. Some Park Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 10 clients receiving medicine ‘as necessary’ rather than regularly, did not have detailed written directions for staff to follow. Clear instructions would make the administration of this type of medication more consistent for residents. The manager was reviewing the use of the key safe in the office. All keys were being transferred to a larger key safe in the manager’s office within the next two weeks. However, the inspector recommended that the keys to the medicine room and the trolley’s should be kept on the person of a senior member of staff for better security. Residents can be sure that, at the time of their death, they and their families and friends will be treated sensitively at Park Hall. Resident’s care plans showed that their wishes had been properly recorded including rites and functions to be observed. One member of staff had taken responsibility for this and should be commended for the detail of these records and the extent to which residents themselves had been involved. There had been a recent death at the home and staff were alert to the effect this was having on other residents. Staff and residents were enabled to attend the funeral and a quiet session was to be held at the home so that residents could remember their friend. Park Hall DS0000033528.V263475.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): 15 Residents at Park Hall receive a wholesome and appealing diet in pleasant surroundings. EVIDENCE: Residents at Park Hall made some very positive comments about the food and on the day of the inspection the homemade steak and kidney pie came in for particular praise. The tables were nicely set and all residents had a drink of blackcurrant or a fortified drink as appropriate. In one of the dementia units the lunchtime activities were observed. Nice music played in the background, and staff were giving assistance where required and in a sensitive manner. The two staff members should be commended for creating a very congenial lunchtime experience for these residents. Some residents commented that in the past the meat had been tough at times and the meals at tea-time were not as good as the lunches. This was discussed with the manager and the chef. There had been recent changes to the meat supplier and it was hoped that the problems with meat had been overcome. As there had also been some concerns about the quality of the meat a county council officer with responsibility for contracting was keeping this matter under review. The manager had already consulted with residents regarding the teatime menu, and new options were being added according to resident’s wishes. At mealtimes the home currently distributes paper hand Park Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 12 towels rather than paper (or cotton) table napkins, and the inspector asked if this could be reviewed. Park Hall DS0000033528.V263475.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): Residents at Park Hall can be confident that their concerns will be listened to and acted upon, and that they will be protected from abuse. EVIDENCE: The County Council’s full complaints procedure has been condensed and put into a format which is more suitable for residents. It appears in the service user guide and residents each have their own copy of this. It is also displayed in communal areas of the home. There have been no complaints since the last inspection, though three written compliments have been received. On the day of the inspection, one of the residents complained of being cold in his room. Staff went to the room in question and adjusted the radiator. Later in the day the gentleman told the inspector he felt much better and was very happy to be back in a warm room. The manager said staff at Park Hall have all had training in the protection of vulnerable adults within the last year. A recent incident at the home reminded everyone that vigilance is always needed. The deputy manager had dealt with the situation very well and in accordance with the local multi-agency procedures for the protection of vulnerable adults. The home has a paper copy of the most recent version of these procedures which is accessible to staff. Park Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 14 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): 19 and 22 Park Hall provides a comfortable and homely environment though some outstanding maintenance issues detract from the otherwise pleasant surroundings. Residents have the equipment they need to maximise their independence. EVIDENCE: Park Hall is situated in a pleasant location and the layout is suitable for its purpose. The premises are now even more accessible as kerbs have been altered and more appropriate door handles fitted outside. The inside of the property is all on one level and accessible to wheelchair users throughout. One of the bedrooms needed some decoration and this was discussed with the manager with a view to replacing a paper border which was peeling off around the room, and covering or replacing a bedside locker which was very damaged. Two maintenance issues remain outstanding from last year and these are the repair of the rear pathway, and repair of the leaking guttering by the front door. Park Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 15 Residents have the equipment they need to maintain their independence. On the intermediate care unit residents are assessed and equipment provided for them by the PIP team. Throughout the rest of the home various aids and adaptations have been provided such as assisted baths and hoists. One of the small ‘quiet areas’ was being used to store wheelchairs and a trolley and the inspector asked if a more suitable storage area could be found. Park Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 16 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): 29 Residents at Park Hall are protected by the home’s recruitment policies. EVIDENCE: Staff demonstrated a good knowledge of sound recruitment practices and stated that they have regard to equal opportunities, take a full employment history, and they always explore any gaps. The new Surrey County Council policy states that staff cannot begin employment until a satisfactory Criminal Records Bureau check has been received. Recruitment practices have changed recently and it was reported that the new arrangements are more cumbersome. There can be a long gap between the interview and the final stages of the process, and good candidates are being lost. Park Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 17 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 and 38. The home is run in the best interests of residents though not all requirements identified by previous inspections have been implemented. Resident’s financial interests are safeguarded. Health and safety is generally well managed at Park Hall but a number of issues need to be remedied in order to comply fully with this Standard. EVIDENCE: A number of examples of resident’s feedback being sought and taken into account were noted. On the issue of teatime meals, residents had been asked for their ideas and favourites, and these had been incorporated into the new menus. Staff had used feedback from the recent in-house activities to plan the forthcoming event programme and Christmas activities, for example the very popular hiring of the karaoke machine. However, Standard 33.10 states that Requirements made by CSCI must be progressed within agreed timescales and Park Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 18 the outstanding maintenance issues have not been addressed following two previous inspections. Some residents at Park Hall require support to manage their money and there is a system, operated by the bursar, whereby residents have ‘accounts’ at the home and this money is kept in a bank account on their behalf. The accounts are well kept with a record of incoming and outgoing monies. When a resident needs the hairdresser, or the chiropodist for example, they sign to say when they have received the service and the fee is taken from their ‘account’. This avoids residents keeping large amounts of cash. For those who wish to keep money and cheque books for example, the home can keep these in the safe at the request of residents. The manager does not act as Appointee for any residents. There are good examples of attention to health and safety matters at Park Hall. The outstanding repairs to the guttering would be much more of a hazard had it not been for the work or the handyman and the manager to make temporary repairs and put up notices advising of the problem around the doorway. Risk assessments are also well done at Park Hall. Areas requiring attention include the removal of boxes, tubs and a machine being temporarily stored in the rear hallway. Though this was not blocking the exit, combustible materials should not be stored, even temporarily, on an escape route. The manager said she would ask the handyman to move these straight away. Sugar was being stored on the floor in the outside storeroom and the agency chef was asked to make other arrangements. The fridges in the kitchens on the units, and in the main kitchen, had items which had been opened and/or cooked and covered, but not labelled with the date of opening. In the main kitchen raw meat was being stored on a shelf higher up in the fridge above items such as mayonnaise and cranberry sauce. The agency chef moved these immediately. In addition, fridge temperatures were not being consistently recorded and in one of the units, the temperature was frequently 8C-9C which is too warm. The Food Standards Agency recommends fridge temperatures should be kept at between 2C-5C. One fridge had a leg missing causing the unit to tip slightly from side to side, spilling the contents of cartons and therefore causing it to be rather messy in this fridge. The hazardous materials (COSHH) cupboard in the sluice was not locked and a member of staff tried several times before it could be locked properly. The COSHH items were safe because the outer door of the sluice is always locked, but the lock on the cupboard door needs to be replaced. Park Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 19 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 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 X X X 2 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Park Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 20 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) Requirement The home must ensure that MAR charts are completed in full and review guidance to staff on the administration of ‘as required’ medications. Guidance should be clearly set out in writing. The medication policy must clearly state who makes decisions on when to administer these types of medication. The home must replace the paper border peeling off one bedroom wall, and cover or replace the damaged bedside locker. The home must find additional storage areas for equipment; see report for details. The home must ensure the premises are free from offensive odours at all times. On the day of the inspection, one small area needed attention in this regard. The County Council must ensure that action is progressed within agreed timescales to implement requirements identified in inspection reports (33.10) and outstanding since 2004/05. DS0000033528.V263475.R01.S.doc Timescale for action 15/12/05 2. OP19 23.(2)(b) 15/12/05 3. 4. OP22 OP26 23(2)(l) 16(2)(k) 15/12/05 22/11/05 5. OP33 23(2)(b) 15/12/05 Park Hall Version 5.0 Page 21 6. OP26 16(2)(k) 7. OP38 13(4)(c ) 8. OP38 13(4)(a) (b)(c ) Therefore an action plan, with timescales, setting out when the broken guttering and cracked outdoor path will be repaired, should be sent to CSCI within two weeks of receiving this report in draft. One small area of the home was not free from offensive odour on the day of the inspection and this must be reviewed and remedied. The items temporarily stored in the rear corridor must be removed and this area kept clear at all times. The home must produce an action plan, with dates, stating when the items highlighted in the final section of the report will be remedied. This should include the following: Replacing the lock on the COSHH cupboard; reviewing fridge temperatures, food labelling and the correct storage of food items within fridges; and repairing the fridge leg which is causing a unit fridge to ‘wobble’. 22/11/05 16/11/05 15/12/05 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. 2. Refer to Standard OP9 OP15 Good Practice Recommendations The medicine trolley keys should be kept carried by a designated senior member of staff, for better security. The home should explore using alternative table napkins at mealtimes. Park Hall DS0000033528.V263475.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Hall DS0000033528.V263475.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. 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. 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