CARE HOMES FOR OLDER PEOPLE
Park House The Parade St Marys Isles of Scilly TR21 0LP Lead Inspector
Paul Freeman Announced Inspection 28th February 2006 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 House DS0000035370.V272977.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 House DS0000035370.V272977.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Park House Address The Parade St Marys Isles of Scilly TR21 0LP 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) 01720 422699 01720 422699 Council of the Isles of Scilly Mrs Lesley Catherine Burrows Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11), Physical disability over 65 years of age (2) of places Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up 2 adults with a Physical Disability (PD [E]) Service users not to exceed a maximum total of 11 Date of last inspection 13th June 2005 Brief Description of the Service: Park House provides long-term care to older people and is situated in the town of St. Mary’s and very close to the sea front. The home has a progressive attitude to community contact, which they actively encourage at every opportunity. The style of care provided is based upon reidents individual needs within which empowerment; dignity, rights and maximising independence are central features. The Home is also committed to ensuring that changing needs are recognised and that the care provided is adjusted accordingly. There are strong links with the carers and friends of residents and the setting has a flexible approach to visiting arrangements. Admissions to the Home are of a planned nature and to assist this process up to four people a day can attend for Day Care and short-term residential care is also available if the resources permit. All service users bedrooms are for single occupancy and the home provides pleasant and comfortable furnishings and décor in all private and communal areas. There is limited outdoor space for service users however, access to the beach is in close proximity for residents users if they wish to spend time in the open air. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned inspection took place on 28 February 2006. A follow up visit had also occurred on 27 September 2005 to consider progress on the requirements and recommendations set following the planned inspection on 13 June 2005. This inspection found that satisfactory progress had been made and the findings will be summarised in this report. The purpose of the inspection was to consider the work that had been undertaken on the requirements set at the last inspection on 13 June 2005 and to inspect other core standards. Therefore some of the key standards considered included care planning, the administration of medication and food. The registered provider, residents and staff were consulted about the services and facilities provided. The environment, records and documents were also considered. The requirements and recommendations set at the last inspection had been worked upon and the provider, staff and residents fully cooperated and were very helpful throughout the inspection period. What the service does well:
Each long term resident that lives at the home is provided with a contract that details their rights and responsibilities. Where a resident is assisted with funding from a third party the home also issue terms and conditions of residency. This document outlines any conditions of residency that are not included in the contact provided by the funding agency. Residents that move to the home are assured their needs will be met and the setting is a suitable place to reside. This is principally achieved through the assessment process undertaken by the providers which makes sure the residents needs can be met by the facilities and services provided. Residents are able to administer their own prescribed medicines where it is safe to do so. Where staff assists residents the medicines are held in secure facilities and are appropriately stored. The staff administering medication have also been trained and a good standard of record keeping is evident. Control drugs are well managed and positive arrangements are in place to safely dispose of any medicines that are no longer required. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 6 The providers have also established a satisfactory policy and procedure that guides, directs and informs the staff to make sure medication is managed safely. Residents said they felt in control of their lives and were confidant that staff positively responded to their requests and any directions they give about the care they receive. It was also evident that residents are able to make their own decisions and are treated in a dignified and respectful manner by staff. Residents were also very positive about the food provided at the home and two residents described the food as “wonderful” and “perfect”. Visitors to the home were also very satisfied with the meals provided and described them as “wholesome” and “good homely cooking”. A varied nutritional menu is provided that reflects the resident’s choices and preferences and is also seasonally adjusted. Residents are able to choose the food they wish to eat at each mealtimes and the provider regularly consults with residents about the menu. The kitchen is well-managed, clean and hygienic and appropriate health and safety measures are in place. The staff in the kitchen is suitably trained and the equipment is regularly serviced and maintained. Residents and their relatives stated that they had no complaints or issues of concern and were confidant about approaching the manager and staff if they had any worries or anxieties about their care or the facilities. They were also confident that any concern would be listened too and acted upon. The environment is well maintained and decorated and residents said it was comfortable and homely. A good standard of cleanliness and hygiene are maintained and residents are provided with appropriate disability equipment to assist their independence. This includes a stair lift between the two floors. There are two communal areas on the ground floor that comprise of a sitting room and lounge/dinning room. A number of bathrooms and toilets are also distributed throughout the home and these facilities are within a reasonable distance from communal areas and residents bedrooms. Residents’ bedrooms are appropriately furnished and all of the rooms have been personalised by the occupant. Residents and their relatives were all complimentary about the care and support provide at the home. Residents said that staff are reliable, responsive and flexible about any needs they have or any requests that are made. It is evident that positive and trusting relationships are in place and residents were confidant they could direct their own care. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 7 It is also clear that sufficient numbers of staff are on duty each day and night and that additional staff are employed at peak times or when needed because of residents needs. The home is well run and managed in a manner that promotes the best interests of the residents. Residents have confidence in the registered manager who they said was approachable and acted promptly on any issues that were raised. The registered provider has also recently appointed a new responsible individual to supervise the management of the home. The providers have put in place suitable arrangements to measure and review the quality of the services and facilities provided. There is also a suitable policy and procedure in place that details the actions that are required. In addition there are reliable arrangements in place for the staff and mangers to informally consult with residents and their visitors about the care and support provided. There is also a range of policies and procedures in place that promotes safe working practices that are designed to make sure that every reasonable step is taken to protect residents and staff. What has improved since the last inspection?
The providers over the last year have significantly improved the care planning arrangements at the home. Each resident has a care plan that details their needs and the care and support required. This makes sure that staff has the information, guidance and direction to meet the needs of residents. The care plans are regularly reviewed with the residents and relatives or representatives views are also taken into account. This makes sure that residents are receiving the care they require and any changes in needs are positively dealt with. The providers have established a rolling programme of redecoration and the temperatures of the heating and water system have been better regulated to make sure that appropriate temperatures are maintained at all times. The training arrangements for staff have improved and an annual programme of training has been established with a suitable mainland training provider. The training is designed to develop the skills and abilities of the staff and make sure that staff has a clear understanding of best practise in regard to the care and support they provide. Arrangements are in place for the staff to be formally supervised on a regular basis. It is also evident that staff are positively supported informally and are able to access advice guidance and assistance when required.
Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 8 The records keeping arrangements at the home continue to improve but are not satisfactory in certain area. Further Improvement is required to meet the regulations and make sure that residents are not inadvertently place at risk. What they could do better:
Residents that stay at the home for short-term care are not provided with a contract or terms and conditions of residency. These documents inform the resident of their resident’s rights and responsibilities while they are at the care home. In certain instances the information provided in care plans could be written clearer to make sure the staff have a clear understanding of the care required. Although the kitchen is decorated to a suitable standard the kitchen units are beginning to look tired and would benefit from replacement or refurbishment. The arrangements to protect residents from abuse require improvement to make sure a robust policy and procedure is in place if any concerns or allegations occur. The manager said that any concerns would be reported to the statutory authorities for investigation. The door widths in the home should be improved so that wheelchair users have easier access around the home. The arrangements to recruit, select and vet staff continue to be unsatisfactory and the records about recruitment do not meet the required standard. Practises must improve to make sure that residents are not inadvertently placed at risk. The responsible individual is required to make monthly visits to the home and provide a written report to the manager and Commission. No reports have received since June 2005 and this shortfall needs to be addressed. The risk assessment and risk management arrangements need to be improved to make sure that suitable guidance and direction is in place when any situation arises that could potentially compromise the health, welfare or wellbeing of residents or staff. The providers also need to make sure that fire drills and staff training in fire precautions measures occurs on a regular basis. This will make sure the staff are very familiar with the arrangements in place. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 9 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 House DS0000035370.V272977.R01.S.doc Version 5.0 Page 10 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 House DS0000035370.V272977.R01.S.doc Version 5.0 Page 11 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): Residents that permanently reside at the home are provided with appropriate information about the terms of residency that confirms their rights. It is not satisfactory that residents that stay at the home for short-term care are not provided with this information. The assessment arrangements for prospective residents determine if the home is able to provide the care and support required. This provides prospective residents with confidence their needs will be met. EVIDENCE: Each resident that resides at the home on a long-term basis is issued with a contact the details the arrangements at the home. Where funding is provided by a third party written terms and conditions of residency are also issued which detail any areas that are not covered in the contact. This provides residents or their representatives with clear information about the terms of residency and provides information about rights and responsibilities. The registered manager said it was not the practise to issues terms and conditions where a resident was staying at the home for short-term care. This
Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 12 needs to be addressed so that all residents are clear about the terms and conditions and their rights while staying at the home. Each prospective resident is assessed to make sure the home is able to meet the person’s needs. The information obtained also identifies the individual’s needs, choices and preferences and is collected in order that a suitable plan of care can be established. All prospective residents are invited to participate in the assessment process. In addition their relatives are representatives are also consulted and the views of any professionals involved with the individual are obtained. This makes sure the providers have a comprehensive picture of the care and support required and confirms to prospective residents and their representatives that their needs will be met. The providers do not offer a dedicated intermediate care or rehabilitation service. The manager said the home is committed to helping residents retain their independence as far as possible. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 13 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 and 9. Care plans need to be more detailed to make sure that resident needs and choices are met. Medication is well managed at the home, which promotes the residents health. EVIDENCE: Since the previous inspection the registered manager and staff have continued to develop care plans positively and they show more clearly the care and support required by residents. Residents said they were “well looked after” and had confidence the staff had a good understanding of their needs, preferences and choices. In certain instances the care plans could be written in a clearer manner to make sure there is good information, guidance and direction for staff. In other instances more information is required about specific needs a resident has. This will make sure the staff has a comprehensive picture of the care and support required. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 14 The evidence indicates that care plans are regularly reviewed to make sure they are up to date and meet with each resident’s approval. The review will also take account of any additional needs a resident may have. Residents are also encouraged to participate in each review and their relatives or representatives are also invited to comment. The care staff said they found plans to be informative, provide valuable information and the plans Also helped them to be aware of the care and support required. Residents are able to administer their own medication when it is safe to do so. Where the staff assists a resident, medicines are held in secure facilities and good records are maintained. The registered manager who is a qualified nurse has also trained the staff administering medication. There are suitable arrangements to dispose of medication that is no longer required and control drugs are well managed. The provider’s have also established a suitable policy and procedure to guide, direct and inform the staff. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 15 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): 14 and 15. Residents are able to exercise control over their lives and direct the care and support provided. A varied, balanced and nutritional diet is provided that promotes residents health. EVIDENCE: Residents said they felt in control of their lives and were confidant that staff positively responded to their requests and any directions they give about the care they receive. It was also evident that residents are able to make their own decisions and are treated in a dignified and respectful manner by staff. Residents were also very positive about the food provided at the home and two residents described the food as “wonderful” and “perfect”. A varied nutritional menu is provided that reflects the resident’s choices and preferences, which is also seasonally adjusted. Residents are able to choose the food they wish to eat at each mealtimes and the provider regularly consults with residents about the meals. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 16 Visitors to the home were also very satisfied with the meals provided and described them as “wholesome” and “good homely cooking”. The catering staff has been suitably trained and the kitchen is clean and hygienic. The equipment in the kitchen is regularly maintained and serviced and satisfactory health and safety practises are in operation. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 17 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. A suitable complaints and whistle blowing policy is in place and residents, their representatives and staff are confident to raise any concerns. The policy and procedure for protecting residents against abuse needs to be improved to make sure residents are safeguarded. EVIDENCE: The providers or the Commission have received no complaints. A satisfactory policy and procedure is in place to deal with any complaints and the provider is committed to dealing with any issues or concerns in a positive and efficient manner. Residents said there were barriers to raising any concerns or complaints and they were confident that any issue would be dealt with promptly and to their satisfaction. The complaint arrangements are appropriately detailed in the homes statement of purpose and service users guide and each resident has access to the complaints policy. The arrangements for protecting residents against any form of abuse remain in the process of development. The registered manager agreed to ensure that the policy is written in line with DOH ‘No Secrets Guidance’ as well as the Local Authorities Adult Protection Procedure. The registered manager stated that plans had been established for staff to receive training about abuse. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 18 The provider has been notified about the need to improve the policy and procedure on at least two previous occasions. It is now imperative that a suitable policy is in place. Failure to comply could result in the Commission considering further action about this matter. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 19 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, 21, 22, 24, and 25. Park house provides a comfortable and homely environment for residents that promotes independence and is regularly maintained to a good standard. EVIDENCE: Residents said they were very satisfied with the facilities provided which they described as homely and comfortable. The home is well maintained and an annual programme of redecoration, maintenance and replacement of furniture and equipment in place. There are reliable arrangements in place to deal with any repairs promptly and efficiently and residents were confidant that any reasonable requests about their living situation would be promptly acted upon. There are two communal areas on the ground floor, a sitting room and a lounge/dining room that meet the required standards. The rooms are comfortably furnished and decorated to a good standard.
Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 20 Residents’ bedrooms are also suitably furnished and equipped and residents are able to bring their own furniture. Therefore the bedrooms have been personalised by the occupants. There are a number of bathrooms and toilets distributed throughout the home and all are within a reasonable distance of the communal areas and residents bedrooms. Theses facilities are also maintained to a satisfactory standard. The home is clean, hygienic and maintained to a good standard. Dedicated staff is on duty each day and residents said the staff were very diligent in the way they undertake their duties. There is a range of disability equipment provided at the home to assist residents to maintain their independence. In addition arrangements are made for individual residents to be assessed by a speaclist worker for aids or disability equipment when required by their individual needs. The three requirements and one recommendation that were set at the last inspection have been acted upon. Consequently a planned redecoration programme is now in place and an architect has been commissioned to look at the width or doors so that residents who are wheelchair users have improved access throughout the home. A satisfactory written agreement has also been established with the Council about the heating and water provision. Officers of the Council have control over the temperatures at the home. The agreement ensures that ambient temperatures are maintained for residents at all times. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 21 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. Park House ensures that suitably trained staff are employed in sufficient numbers at all times. The recruitment checks are not carried out as required by regulation and this could place residents at risk. EVIDENCE: Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 22 From discussion with residents and their representatives and staff plus the inspection of staff rosters, it is evident that there sufficient numbers of staff on duty each day and overnight. There are no concerns about the experience or manner in which the staff provide care. Residents spoke positively about the care and support staff provide. The residents said they found the staff to be reliable, responsive and skilled in the manner they undertake their duties. Residents also stated they were able to direct the care and support they receive and it was evident that positive and trusting relationships have been established. At the last inspection the providers were required to improve the arrangements in respect of recruitment and staff training. Following the last in section an appropriate training programme for the staff group has been in place with a training provider on the mainland. There are no evident immediate concerns about the staff skills and abilities and training therefore is designed to develop the services provided and make sure staff are up to date in regard to the care and support they provide. Many of the staff is trained to NVQ 2 standard and arrangements are being finalised with the training providers for addition staff to commence this qualification. Staff that had recently commenced at the home said they had received a positive induction and were well supported in their work. The recruitment, selection and vetting arrangements have improved but further improvement is required. The Councils Human Resources Department assists with the recruitment process and staff files are now held at the home. However there continues to be documents and records required by regulation that were incomplete or not available for inspection. These included references, terms and conditions of employment and Criminal Records Bureau checks. The requirement is therefore renotified. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 23 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, 33, 35, 36, 37 and 38. The home is well run for the benefit of residents. The responsible individual has recently changed but reports of the monthly visits to monitor the management arrangements, which are required by regulation, are not regularly received. The quality of the services and facilities are reviewed but more robust arrangements are being developed. This will make sure the home is run in the residents’ best interests. Records at the home continue to improve but further development is required to make sure clear and comprehensive information is in place. The safe working practises at the home require improvement so that residents and staff are not inadvertently placed at risk. EVIDENCE: The home is well run and managed and residents said they felt in control of their lives. Comments from residents and staff in respect of the registered
Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 24 manager were positive, seeing her contribution to the home as valuable, supportive and a ‘good listener’. All felt they could approach her with any concerns or queries. In addition the manager has been allocated additional dedicated management time but this has been recently interrupted due to staff illness. Staff have now returned to work and the managers is confidant appropriate time will now be available. The Responsible Individual who represents the registered provider has recently changed. Previous requirements in respect for the Responsible Individual to provide monthly reports on the home are re-notified. No reports appear to have been received since June 2005. The manager said they have established arrangements to make sure that staff are regularly formally supervised. The informal support and supervision to staff is evidently robust and reliable. The providers have established arrangements to review the services and facilities on an annual basis with residents, visitors and professionals that have contact with the home. To assist this process a policy and procedure is in place that guides and directs the action to be taken. The quality assurance measures are also supported by the positive informal consultations and discussion that occur between staff, residents’ and visitors to the home. It was found that residents have been consulted but the actions detailed in the policy and procedure had not been fully completed. The manager said this would occur during 2006. Residents were very confidant that the home is run in a manner that promotes their best interests. Records at the home continue to improve but overall do not currently meet with the standards required by regulation. However records held by the home are stored in a confidential manner and in line with the Data Protection Act. There are a range of policies and procedures in place to promote safe working practises and these include infection control, risk assessment and management, fire safety and food safety and hygiene. A number of policies were sampled that appeared to be robust and meet the standards required. Other policies and procedures required further development to make sure that residents and staff are not inadvertently placed at risk. The fire safety arrangements in place are currently being reviewed and developed with the Fire Officer. This includes the homes risk assessment and staff training. Staff are currently trained on an annual basis but it is advised this is increased to make sure staff are fully prepared to deal with any
Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 25 incidents. Equally fire drills are undertaken but the frequency needs to be improved. The evidence indicates that fire equipment and the emergency lighting is regularly monitored and maintained. Accidents that occur are recorded but the information provided is not always complete. The risk assessment and risk management arrangements continue to be developed but they are always completed or provide staff with sufficient guidance and direction. Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 26 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 2 X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 2 X 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 2 2 Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 27 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. Standard 1. OP7 Regulation 15(1) Requirement Service users care plans must be developed further to make sure their is clear guidance about the care and support required. The kitchen units must be maintained to a suitable standard. Adult protection policy and procedures must be amended to meet the national minimum standards. This is re notified to you. All pre-employment checks must be carried out before staff members commence work. This is re notified to you. Staff must be provided with up to date terms and conditions of employment and job descriptions. The responsible individual must provide written reports of his monthly visit as required by the minimum standards. This is re notified to you. Robust quality assurance measures must be in place that includes an annual report that is shared with all interested parties. Records must be kept in line with the requirements as set in
DS0000035370.V272977.R01.S.doc Timescale for action 30/07/06 2. 3. OP15 OP18 13(4)c 16(2)g 12,1a, b,2,5 b,13,6 19,1,2 3,4,5, S4(6) 17 (2) Sch 4(6)f 26(1)(3) (4)(5) 30/12/06 30/04/06 4. OP29 30/05/06 5. 6. OP29 OP31 30/04/06 30/05/06 7. OP33 24(1-3) 30/12/06 8. OP37 17, Sch 3 &4 30/07/06 Park House Version 5.0 Page 28 9. OP38 13(4)a-c 10 OP38 23 (4)c-e Schedule 3 and 4 of the regulations. This is re-notified to you. Robust arrangements must be in place to assess and manage risks at the home or experienced by service users. Fire training and drills must be undertaken on a regular basis that reflects good practise standards. 30/05/06 30/04/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP2 Good Practice Recommendations Service users that stay at the home for short-term care should be provided with a contract and terms and conditions of residency where funding is provided by a third party. The width of doors should be increased to maximise access for wheelchair users. 2. OP22 Park House DS0000035370.V272977.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 House DS0000035370.V272977.R01.S.doc Version 5.0 Page 30 - 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!
