Inspection on 03/10/06 for Park Hall Resource Centre

This inspection was carried out on 3rd October 2006.

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

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

Other inspections for this house

Park Hall Resource Centre 28/10/08

Park Hall Resource Centre 15/11/05

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 Key Unannounced Inspection 3rd October 2006 10:00 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.V313973.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 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 Rachel.Darcy@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 (2), 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.V313973.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Abbey Unit will be exclusively for the provision and/or Intermediate Care to a maximum of 10 Service Users. 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. 15th November 2005 Date of last inspection Brief Description of the Service: Park Hall is located in a quiet residential area on the outskirts of Reigate. Surrey County Council operates the care home. Care and accommodation is provided to older people, some of whom have dementia. It is purpose built and of modern design. Accommodation is arranged in five units all of which are at ground floor level. Each unit has its own bathroom and toilet facilities and a communal lounge/dining area. All bedrooms are single. Additional facilities include the day centre, offices, meeting rooms and kitchen. The home has ample off street parking and an enclosed garden. Surrey County Council is considering extending the home to provide nursing care and accommodation. The cost person is at Park Hall is £543 per week. Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over 8 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to June 2007. All the key National Minimum Standards for Older People where assessed. The inspection was carried out by Helen Dickens, Lead Inspector for the service. Sharon Woodings, Registered Manager, and Rachel Darcy, deputy team leader, represented the establishment. A tour of the premises took place and the inspector spoke with 14 residents either individually or in small groups, meeting most of the remaining residents during the tour of the building and at lunchtime. In addition to the registered manager, three staff were spoken to, and a number of documents and files examined as part of the inspection process. The inspector would like to thank the residents, staff, and the Registered Manager and her deputy, for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 6 Improvements since the last inspection include the guttering, which has been repaired, new medicine trolleys have been purchased, and the reception desk has been moved into the front hall to improve security arrangements. A privacy screen has been purchased for use if residents become unwell or need attention whilst in the communal areas. A freshwater chiller has been purchased for the use of residents and staff and placed in the reception area, and the sensory room has been cleared out and is now fully functional with comfortable seating and special lighting and equipment. A member of staff has started a weekly book review session for residents on Thursday evenings in the bar area of Park Hall. New staff have been recruited including a laundry assistant and one night and one daytime senior care staff. Two bank workers and one full time care worker have also been recruited. One senior staff member has started fortnightly workshop training sessions for staff. 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.V313973.R01.S.doc Version 5.2 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.V313973.R01.S.doc Version 5.2 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): 3 and 6 Residents who move into this home are assured their needs will be met and those admitted solely for intermediate care are helped to maximise their independence and return home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three resident’s files were sampled and each had a good record of their initial community care assessments. Some also had other specialist assessments such as occupational therapy assessments. Residents spoken to confirmed their needs were being met, including some who were there for short stays. When asked if they were receiving all the help they needed, one resident described Park Hall as a ‘home from home’ in that respect. Intermediate care is provided on Abbey Unit and there were 3 intermediate care clients on the day of the inspection. The manager said this is the average number because some of the other beds on that unit are used for respite. There was good feedback from external professionals who provided support on Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 9 this Unit including ‘Staff respond promptly to the needs of patients’ and another wrote that Park Hall ‘…offers a high standard of care.’ A thank you card in the ‘compliments file’ at the home was from a satisfied service user who had been on the Unit following a fall and was grateful for all the help she had received to get her back on her feet. One relative was so pleased with the high standard of care and rehabilitation taking place at Park Hall that they sent a copy of the ‘thank you’ letter to the local paper who published this, along with the names of individuals who had been particularly helpful, and noted that the home generally is ‘very worthy of praise.’ Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 10 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): 7,8,9 and 10 Care plans are well done at this home and the health care needs of residents are met. Arrangements for the administration of medication are good and residents are treated respectfully by staff. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are well done at this home and there was evidence these had been compiled from the initial community care assessments, with input from other professionals as necessary. Residents spoken to confirmed their needs were being met and there was evidence from care plans that residents had been involved in drawing them up. There were risk assessments on file and the plans were regularly reviewed. The registered manager was asked to fine tune how the plans were currently being reviewed to ensure that all reviews were accurately documented. Resident’s health needs are well met at this home. There was positive feedback from health professionals and residents spoken to stated they had sufficient assistance with their health needs for example nurses were coming in Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 11 to treat leg ulcers, or to advise on matters such as continence, and specialist nurses were overseeing the care of those on the dementia units. Some issues highlighted by visiting health professionals on their returned comment cards were raised with the manager for future reference. There are policies and procedures in place regarding the administration of medication at this home and recent improvements have included the purchase of individual medication trolleys for each wing which are kept centrally in a medication room. One medication administration session was observed and three medication administration records (MARs) sampled. Medication was observed to be kept securely, administered sensitively to each resident, and there were no unexplained gaps on the MARs sampled. One returned comment card from an external professional noted there had been problems with residents running out of medication. The registered manager said this had been when residents had come directly from hospital with limited supplies, and she said this had since been reviewed and remedied. Residents were observed to be treated respectfully by staff. During the course of the inspection there were many examples of this such as staff always knocked on resident’s bedroom doors and toilet doors before entering, a senior staff member who joined a conversation between the inspector and a resident (to add some useful information) first asked the resident if she could interrupt, and other staff were seen to announce their arrival on each wing and let residents know when they were leaving. Those who needed help at mealtimes were given this is an unobtrusive way and those who wished to manage this themselves were assisted to maintain their independence by special arrangements such as adapted cutlery or eating on their lap. Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 12 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): 12,13,14 and 15. Routines and activities are arranged to suit resident’s preferences and family and community contact encouraged. Residents are supported to make choices in their daily lives, and are offered a balanced diet. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Routines and activities are suited to resident’s expectations and preferences. There was evidence of activities throughout the day of the unannounced inspection. The ‘concourse’ is the focus for the day centre activities and those who had come for the day were enthusiastic about the activities on offer. After morning coffee there was a group of four people playing dominoes, and two ladies painting. Six or so others were taking part in a chair based exercise of throwing hoops and several others were either reading the paper or doing word puzzles. Yet others were sitting chatting in small groups. Residents and visitors to the day centre listed their favourite Park Hall activities including the bingo, quizzes and cooking. Physical exercises were also popular. One member of staff has now started doing a ‘book review’ on Thursday evenings with residents who also have drinks and snacks at the Park Hall ‘bar’. Resident’s preferences regarding social activities are recorded on their care plans. A few negative comments were received on returned comment cards, especially Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 13 about the availability of mental stimulation, and these were discussed both with residents and staff. Family and community contact is encouraged at this home and residents are able to receive visitors in private. Comment cards from visitors were very positive and included comments such as ‘The care is outstanding’; and thanking staff for ‘..the hospitality when we visit.’ As mentioned above, one resident’s relatives sent their ‘thank you’ letter to the local paper. A few issues raised by relatives on these comment cards were discussed with the manager. One such issue was regarding a resident’s clothes going missing and the registered manager said there had been problems with laundry but they had now managed to recruit a permanent member of staff for this post and were expecting things to improve. Residents at this home do have opportunities to exercise autonomy and choice. This is documented on care plans and in residents meetings for example. Residents commented on the extent to which they were able to exercise choice for example with regard to meals, whether and which activities to join, and in styling their bedrooms which were all very individual with resident’s personal possessions clearly evident. Residents are offered a varied menu and have a choice of meals each day. One resident who has a special vegetarian diet said she has a combination of home cooked and bought meals of her choice and the home have now provided her with her own personal weekly menu. It was noted that each unit had their own supply of fresh fruit for residents to enjoy either during the day or after meals. On the day of the inspection the two optional main courses were lasagne or cheese and potato pie; both were tasted by the inspector and found to be tasty - the latter was excellent. There was a homemade fruit crumble for pudding. There were two vegetables served with the main course. Some residents on one unit had chosen the lasagne but said they were not really lasagne ‘fans’; however they finished their meals and seemed to have enjoyed what they had. It wasn’t clear why they had not chosen another option (e.g. every day there is either baked potatoes or omelettes and salad available) and the registered manager was asked to review how staff are offering choices to residents. All residents have the menu read to them the day before, and choose what they would like; it was suggested that the regular alternatives be printed on the menu as well and read out or shown to residents each time. Though the registered manager said paper napkins had now been purchased, none were out on the tables at lunchtime; she said she would ensure staff knew were to get fresh supplies. The fridges on each unit need to be more closely monitored as one had opened but unlabelled/undated food and a recorded fridge temperature which was twice the recommended level. Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 14 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 Resident’s concerns are taken seriously at Park Hall and they are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure and residents meetings begin with an opportunity for residents to raise concerns. No complaints have been received by CSCI about this home since the last inspection, and the home itself has received one. This was dealt with to the satisfaction of the person raising the concern. The home has received a number of compliments and ‘thank you’ letters and these are mentioned elsewhere in the report. Residents at this home are protected from abuse. A copy of the countywide protection of vulnerable adults policy is available to staff and staff files sampled showed training on this subject had been given. Three issues had been raised since the last inspection and the home dealt with each of these according the correct procedure. Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 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): 19 and 26 The environment is generally safe, well maintained, clean and hygienic, but some areas needed attention to meet these Standards in full. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Park Hall provides a comfortable and homely environment. The larger home is divided into smaller Units, and each has it’s own lounge/dining room which are comfortably furnished. There are communal areas such as the concourse and library where residents meet for social activities, and a number of ‘quiet areas’ throughout the building. In addition there is a sensory room with special lighting and other equipment for the benefit of residents. Arrangements are in place to comply with fire and environmental health requirements. However, some unmet Requirements from previous inspections have still not been actioned including the pathway at the back where a tree root has broken the path and is now covered in moss. The registered manager said residents do not use this path and it will be cordoned off to ensure it is not used until it Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 16 can be repaired. Paper borders are peeling off some walls, and hoists are still being charged and stored in the quiet areas - both of these matters were highlighted at the last inspection. The manger said as rooms are being redecorated the paper borders are being removed, and the home will consider using empty bedrooms for charging and storing hoists. In addition to the above, the home has had some subsidence and two bedrooms have now become unusable as bedrooms. This matter was first discovered in May but despite monitoring by an external agency, no remedial work has so far been carried out. It was also noted that the standard of gardening has deteriorated and most patio areas had weeds and moss growing and needed some attention. The registered manager said that the handyperson/gardener was very good and was doing his best in the hours available. The handyperson/gardening resources may need to be reviewed. The home was generally clean and well kept and two full time domestic staff are employed to keep both resident’s bedrooms and communal areas clean and tidy. Hand washing facilities were good and a new member of staff recently recruited to manage the laundry facilities. However, on the day of the inspection, one area of the home was not free from offensive odours and this was discussed with both the deputy and the registered manager. The difficulties surrounding this issue were explained to the inspector but nevertheless more suitable arrangements must be made. Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 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): 27,28,29 and 30. Resident’s needs are met by the skill mix of staff and residents are in safe hands. Recruitment processes are good and staff are trained and competent to do their jobs. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection staff rotas were sampled and there were sufficient staff on duty to meet resident’s needs. Residents spoken to confirmed that staff gave them all the assistance they asked for and one said ‘Staff are excellent – nothing is too much trouble for them.’ However, some returned comment cards mentioned the apparent shortage of staff at certain times. The deputy manager said this had probably been when the Abbey unit was closed and staff numbers had been reduced. The registered manager was asked to use the Residential Forum matrix to calculate staff to resident ratios. Staff training is taken seriously at this home and currently 22 of the 28 staff have NVQ2 or above, exceeding the 50 target set out in Standard 28. When the qualifications of agency staff are taken into account, this home still exceeds the target. Recruitment files at this home are well organised and staff files examined showed the necessary employment checks had been taken up. The home’s registered manager was asked to ensure that each candidate filled in their employment history giving the month, not just the year, when they had Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 18 changed employment. The registered manager said that the county council were in the process of going back and re-checking those staff that had been in employment before July 2004 and getting new CRB checks, which would now include the pova check. No new staff are allowed to start at Park Hall until the CRB and pova check are returned and deemed satisfactory. The staff files examined included two new staff who were still undergoing their induction process and had had separate training courses including protecting vulnerable adults, manual handling, and food handling and hygiene. The induction folders showed both staff had been covering topics such as safe working practices, the care workers role, and the needs of this particular client group. One staff file examined had no information regarding induction and the member of staff who had been working at the home for some years confirmed she had had no induction. Practices now are stricter and induction processes are good. Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 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): 31,32,33,35,36,37 and 38. The home is well managed with an open and positive atmosphere for staff and residents. Quality assurance processes are in place but more work needs to be done to meet this Standard in full. Resident’s financial interests are safeguarded. Formal staff supervision sessions need to be more frequent at Park Hall. Record keeping is good though more work needs to be done regarding the health and safety of residents and staff. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is qualified, competent and experienced – she has been at Park Hall since 2003 and is responsible for no more than one registered establishment. She and senior staff are knowledgeable on conditions relevant to this client group. Training records sampled showed the range of training courses attended by staff and these included dementia care, Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 20 continence training, and MRSA and infection control training. There are clear lines of accountability within the home. The management approach of the home is open and positive. There was a happy and pleasant atmosphere and residents felt free give their opinions to the inspector. During lunch in one unit for example, residents had no hesitation in giving their honest opinions about lunch (several expressed reservations about lasagne) with the registered manager standing beside them. The registered manager communicates a clear sense of direction and leadership and there are a number of ways (set out under Standard 33) in which staff and residents can influence the way the service is delivered. Quality assurance processes at this home include regulation 26 visits by the registered provider (Surrey County Council), staff and resident’s meetings, and ad hoc information gathering exercises, such as collating resident’s ideas about food and menus. There are also client reviews and an internal quality assurance process. Client’s reviews with social services and others also provide an opportunity to gain feedback on the care of individual residents. Resident’s meetings held on individual units were sampled and it was noted that comments and suggestions from residents regarding food and other issues had been raised and what actions were going to be taken. One of the Units had already held four resident’s meetings so far this year. There is also a day centre meeting. The home keeps a file of compliments and, in addition to the article in the local paper mentioned earlier, other comments included ‘I can’t put into words my gratitude to you all’; ‘The care is outstanding’ (from a relative); and ‘I Would like to thank you all for the care and compassion shown to our relative.’ However, the registered manager said that Park Hall and the home they are currently paired with are behind with their internal quality assurance processes, and there is no written annual development plan as set out in Standard 33.2. The home also do not currently have resident’s surveys or systematically gain feedback from other stakeholders (Standard 33.4 and 33.7.). At the last three inspections, Requirements were made regarding the external premises and one of these (regarding the trip hazard on the path at the rear of the home) has still not been met. Standard 33.10 sets out that action is progressed within agreed timescales to implement Requirements identified in inspection reports. 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. No accounts were checked at this inspection but on the last inspection accounts were found to be well kept with a record of incoming and outgoing monies. For those who wish to keep money and cheque books for example, the home can keep these Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 21 in the safe at the request of the resident. The manager does not act as Appointee for any resident. There is a system of staff supervision in place at the home and a senior member of staff has also started a new ‘training’ session for all staff on duty, once a fortnight, reinforcing existing good practice and offering advice/guidance on a range of relevant subjects. However, of those staff files sampled, not all staff had had sufficient documented formal supervision sessions this year to enable them to reach the six recommended sessions as set down in Standard 36.2. Records are well kept at this home and of those sampled (e.g. resident’s files, staff files, rotas, menus and maintenance and safety certificates) all were in good order and where appropriate, and they were being securely kept. The recruitment files were in particularly good order with a contents page at the front and dividers throughout each file so that individual records could be accessed easily. One CRB had accidentally been filed on a recruitment file and the registered manager removed this immediately. The inspector advised that the home should look at the CRB website for up-to-date advice on the correct storage and disposal of CRB information. The registered manager and staff work hard to ensure the safety of residents and a number of risk assessments (e.g. on manual handling and mobility for example) were in place to protect residents in their day-to-day lives. Staff also receive training on health and safety issues and during the last year this has included first aid, fire safety, manual handling, food hygiene, infection control, and the protection of vulnerable adults. Some staff have also had training in risk assessments. A number of documents and certificates were examined including the electrical PAT testing certificate (29/9/06); certificate showing their hospital beds had been serviced; fire extinguishers had been checked (February 06); and the emergency lighting and fire alarms had been checked (23/06/06). The Environmental Health Officers report showed that the home had scored ‘unsatisfactory’ on some issues and this was discussed with the registered manager who said that all the matters highlighted had now been satisfactorily dealt with. One senior member of staff is responsible for health safety within the home and the County council are planning to implement new health and safety arrangements across all their homes in the near future. However, there were a number of issues that might affect the safety of service users, some mentioned earlier, and including; • • Weeds and moss on patios and paths around the property which could cause slips or trips The tree roots and moss on the rear pathway which has been the subject of requirements for the last three inspections and still not remedied Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 22 • • • • • • Subsidence on one unit which means two rooms and an outside area are cordoned off - no information was available on how this matter would be resolved. A concrete ramp to one unit has a gap between the ramp and the brickwork which could be a trip hazard. The faulty lock on one hazardous substances cupboard in one sluice room has not been repaired since the last inspection (though the door to the sluice was locked with a small bolt). These substances were removed to another area which was more secure. One fridge had food which had been opened and removed from original packaging but was unlabelled and there was no evidence of the date these had been opened; fridge temperatures were recorded as double the recommended maximum but no action taken. A number of creams and lotions were being stored in one quiet area in a cupboard which was not locked; these were removed immediately. One new resident needed a mobility risk assessment as they walked with a walking frame. Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 3 2 Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23(2)(b) (l)(o) Requirement The registered person must review/remedy the following issues highlighted during the inspection: • The paper border peeling off some bedroom and corridor walls (Outstanding from 15/12/06) • Hoists stored and charged in quiet areas. (Outstanding from 15/12/06) • The deteriorating garden/patio areas. • The actions/timescale to remedy the subsidence damage. The registered person must ensure the premises are free from offensive odours at all times. (Outstanding from 22/11/06) The registered person must ensure that a full employment history on recruitment files includes giving the month, not just the year when the person DS0000033528.V313973.R01.S.doc Timescale for action 03/11/06 2. OP26 23(2)(d) 05/10/06 3. OP29 19(1)(b) Schedule 2 03/11/06 Park Hall Version 5.2 Page 25 4. OP33 24(1) 5. OP33 23(2)(b) 24(2)(c ) changed jobs. The registered person must 03/12/06 establish and maintain a system for evaluating the quality of services at Park Hall having particular regard to an annual development plan for the home, and service user surveys, both of which are set out in Standard 33. The registered person must also have regard to the SCC internal quality assurance policy, which is currently behind schedule for this year. The County Council must ensure 24/10/06 that action is progressed within agreed timescales to implement requirements identified in inspection reports (33.10) and outstanding since 2004/05. Therefore an action plan, with timescales, setting out when the cracked outdoor path will be repaired, should be sent to CSCI within two weeks of receiving this report in draft. (Outstanding since 22/12/04) The registered person must ensure that staff are regularly supervised as set out in Standard 36.2. The home must produce an improvement plan, with remedial actions and dates, stating how and when the items highlighted in the final section of the report (and in the previous 6 Requirements above) will be remedied. 03/11/06 6. OP36 18(2)(a) 7. OP38 13(4)(a)( b)(c ) 24A 10/11/06 Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 26 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 OP7 Good Practice Recommendations The registered manager should ‘fine tune’ the arrangements for reviewing care plans as discussed during the inspection to ensure monthly reviews of the whole care plan are carried out for all residents. Napkins, rather than paper hand towels should be available in the dining areas for residents use. The fridges on each unit should be more closely monitored as one had opened but unlabelled/undated food and a recorded fridge temperature, which was twice the recommended temperature. The registered person should use the Residential Forum matrix to calculate staff to resident ratios. The registered person should review the CRB website for information and advice on the correct storage and destruction of CRB certificates. 2. 3. OP15 OP15 4. 5. OP27 OP29 Park Hall DS0000033528.V313973.R01.S.doc Version 5.2 Page 27 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.V313973.R01.S.doc Version 5.2 Page 28 - 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!