Inspection on 31/08/05 for Park House Care Home

This inspection was carried out on 31st August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 House Care Home 29/11/07

Park House Care Home 02/05/07

Park House Care Home 17/01/07

Park House Care Home 29/09/06

Park House Care Home 11/11/05

Park House Care Home 25/01/05

Park House Care Home 19/05/04

Park House Care Home 24/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Emmanuel Christian Care Home - Park House 1 Palm Grove Prenton Birkenhead, Wirral CH43 4Uu Lead Inspector Jeanette Fielding Unannounced 30 & 31 August 2005 09:50 hours th st The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Emmanuel Christian Care Home Address 1 Palm Grove Prenton Birkenhead Wirral CH43 4UU 0151 652 1021 N/a N/a Gladman Care Homes (Emmanuel Christian Care Home) Ltd Bryn Williams Care Home with Nursing 111 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of DE(E) Dementia - 65 years and over - number registration, with number of places (41) of places OP Old age - years and over - number of places (70) Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 70 (OP - Nursing Care), 8 (OP - Personal Care) in the overall number of 70 41 (DE/E) Four named service users under the age of 65 years for OP Nursing Care Date of last inspection 25th January 2005 Brief Description of the Service: Emmanuel Christian Care Home is situated in a quiet residential area of Prenton in Birkenhead. It is owned by Gladman Care Homes Limited and was registered as a care home for Older People on 28th August 2002. The Home is purpose built and dual registered for care of the older person requiring personal care and nursing care. The home has one hundred and eleven registered places, forty of which are for providing care for service users suffering from age related mental health conditions in the overall number of one hundred and eleven. The home provides bedrooms on all floors of the building, the EMI Unit is housed on the first floor and the ground and second floors are used to provide either general nursing or personal care. The home is centrally heated and each floor has several spacious lounges. There are an adequate number of toilet and bathrooms, and each room has an en-suite facility. The home has two lifts to each floor as well as several stairways. The home is accessible by public transport and there are a variety of local shops nearby. The home provides both trained staff (RMN’s and RGN’s) as well as experienced care staff twenty-four hours a day. There are separate domestic, laundry and kitchen staff as well as a maintenance person. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over two consecutive days. A total of fifteen hours was spent in the home. The inspector spoke with eighteen service users and four relatives to obtain their views of the home. Meetings were held with the management and a high number of staff, from all departments within the home, were interviewed. Records relating to the care of service users were inspected and this included service users who had recently been admitted to the home and those who had been in for some considerable time. These showed that whilst most care files were detailed, informative and up to date, some required to be reviewed and updated to reflect the service users changing care needs. A nurse practitioner is allocated to the home to assist in ensuring that all health care issues are addressed effectively and efficiently. Staff records provided evidence that all checks had been made to ensure the protection of service users. Recruitment procedures are robust and the records provide evidence of continued training for all staff. A tour of the premises showed that all areas of the home were tastefully decorated and appropriately furnished and that all décor and furnishings were in good condition. The home is bright and pleasant throughout and provides a range of facilities and amenities to assist service users. Two shower rooms on the first floor require attention to bring them up to acceptable standards. Arrangements for this to be addressed were made at the time of the inspection. Apart from one worktop, and the shower rooms, all areas of the home were clean and free from offensive odours. It is evident that staff strive to provide a pleasant and homely environment for the service users. A small number of discrepancies were noted in the recording of medication and in the medications received from the pharmacist. This will be dealt with by the manager. Towels were seen to be in a poor condition and require replacement and staff reported that there was a lack of bedding. Sufficient and suitable linens are to be provided. A range of meals is provided for service users to choose from, although the transportation of meals requires to be reviewed and improved. What the service does well: The home is bright and modern and provides service users with a pleasant environment to live in. The management of the home is robust and improvements continue to enhance the quality of life for the service users. A high level of training is given to staff at induction. Choices are offered in all aspects of daily living and individual preferences are recorded on care files. A nurse practitioner has been allocated to the home to assist in ensuring that all health care issues are addressed effectively and efficiently. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 6 What has improved 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. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 6 The homes Statement of Purpose is good providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to the home. EVIDENCE: The home’s Statement of Purpose has now been reviewed and updated to reflect the changes and improvements that have taken place within the home. This document gives full information regarding the services and facilities that are provided. Copies of the Statement of Purpose are available from the home on request. The manager has recently reviewed and improved the pre-admission assessment form, for those service users who are accommodated for general nursing or personal care, to ensure that prospective service users needs are clearly identified and an initial plan of care can be prepared from the information gathered. The care files for those service users who have recently been admitted to the home, following the implementation of the new forms, were inspected and were found to be extremely detailed and informative. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 9 These assessments are undertaken by the registered nurse in charge of the unit where the service user is to be admitted. The manager is now looking to improve the pre-admission assessment form for those service users who will be accommodated by reason of their mental health problems. The assessment of service users identifies their specific care needs together with information regarding their social, dietary, mobility and safety requirements and enables the home to obtain appropriate equipment or aids prior to their admission. The home does not offer intermediate care. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 The staff have a good understanding of the service user’s care needs and this information will be recorded within individual care plans to ensure the protection of service users. EVIDENCE: Individual care plans are prepared for each service user. Some of these were noted not to have been updated on a regular basis to reflect the changing needs of the service users. Discussion took place with senior staff regarding different methods of managing and reviewing care files and plans are now in place for a full programme of review and monitoring of files to ensure that they hold all necessary information. The records held in the home show that some records are held separately from the care files i.e. diaries, and this information has not always been transferred to the care files. Systems for co-ordinating and recording information appropriately is now being established. Staff spoken to were clearly able to demonstrate that they were aware of each individual service users needs and of how those needs were being met. The majority of risk assessments were detailed and included all information to ensure that any identified risks were managed appropriately and that were risks can be removed, appropriate systems were in place. A few risk Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 11 assessments require to be reviewed and updated to reflect the changing needs of the service users. One bed rail was seen to be insufficiently high due to an overlay mattress being placed on the bed and arrangements were made for this to be replaced during the course of the inspection. Risk assessments in relation to managing challenging behaviour require improvement to give staff full information regarding the diversional programmes to be put in place to implement when service users are not able to deal with their problems without intervention. Some nutritional assessments require to be put in place or reviewed to give staff full information regarding the dietary needs of the service users. Service users and their family or advocates are involved in the preparation of care plans and appropriate measures are in place to provide evidence of agreement with the plan. A system for ensuring that the health needs of each service user has been implemented within the home. A total of twelve GP’s are involved in the home and so to reduce the pressure on the GP’s and to streamline the service provided, a Nurse Practitioner is employed by the PCT to provide a liaison facility between the home and the GP’s. The Nurse Practitioner is permitted to prescribe some medications and will arrange GP visits where necessary. Both the home and the Nurse Practitioner said that this service has enabled a streamlined and co-ordinated health care provision to be implemented and had proved extremely successful. Full details of any recommendations of the Nurse Practitioner or the GP are clearly detailed in the home. Records are also held in the home of visits to and by other healthcare professionals e.g. Tissue Viability Nurse, Continence Advisor and District Nurse and of any recommendations made by them. The medications within the home are administered to service users by the qualified nurse on duty in each area of the home. The home has a policy and procedure to be followed for service users who wish to hold and administer their own medications and these are implemented as appropriate. An inspection of all medications held in the home was undertaken. It is evident that some staff are not following the home’s procedure for the administration of medications. Blank spaces were found on some Medication Administration Record sheets where staff have failed to sign to provide evidence that they have administered a medication. One medication was found to have been incorrectly counted, and although a further check found that the medications were all accounted for, the records were incorrect. A large amount of medications were found to be returned to the dispensing pharmacist on a regular basis and the manager is strongly advised to liaise with the dispensing pharmacist to ensure that items not included on doctors prescriptions are not sent to the home. The home’s procedure requires that Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 12 handwritten medications are witnessed by a second person and the number of medications entering the home are recorded. In a few cases, the procedure had not been followed adequately. The manager is advised to review the training of staff who administer the medications in relation to the home’s policy and procedure and to obtain an undertaking from these staff that they will follow the procedure. The arrangements for the disposal of medications in homes has recently been changed by legislation. The home is currently reviewing the system in place for disposing of small amounts of medication and is seeking information from local disposal companies to ensure that the most efficient and safe method is identified. Discussion took place with the manager regarding the information recorded on care files relating to those medications which are prescribed on a ‘when needed’ basis. The care files did not give sufficient information regarding the service users ability to inform staff of their need for such medication where mental health problems deny them the ability to communicate i.e. when a painkiller is required. The manager will work with the senior staff and the service users to ensure that this information is recorded. Service users are accommodated in single bedrooms and personal care is given in their bedroom, the en-suite facility or the bathroom as appropriate. Service users spoken to confirmed that their privacy and dignity were respected at all times and that staff knocked on their door prior to entering. Visitors to the home also confirmed that they had observed privacy and dignity being respected and one visitor stated that he was extremely happy with the care given, having moved his relative from another home. He said that he could relate to both good and poor practice and found the practice within this home to be very good. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: The activities co-ordinator has recently left her position and the home is actively seeking a replacement. The activities programme has been extremely well appreciated by the service users and the staff are doing all they can to provide activities and stimulation whilst a replacement is recruited. Service users spoken to during the inspection said they had an active social life and were able to choose from a range of activities. Service users who did not wish to join in group activities were given one to one stimulation and a record is held in the home of all activities that take place. Ministers of religion visit the home regularly and provide services. At the time of the inspection, one group of service users were enjoying a hymn singing session and staff were encouraging and supportive of this. The care files give details of service users individual preferences and choices and the daily reports show that their preferences were respected. Visitors spoken to during the inspection were extremely positive about the home. Comments made provided evidence that care needs were met and that Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 14 they were consulted on all aspects of their relatives care. Some relatives take the service users out and one service user said she enjoyed going to the local park during the warm weather. Risk assessments were in place for those service users who go out. Meals are served to service users in their bedroom, the lounge or the dining room according to their individual preferences. Breakfast is available from 8.00 am until mid morning as the service users wish. The main meal is served at lunchtime with a lighter meal in the evening. Snacks are provided between meals and supper is available at a time of service users choosing. Meals are prepared in the main kitchen which was seen to be clean and organised. Meals are transported in heated trolleys to the smaller kitchens which are located in the dining rooms on each floor of the home. The staff on the first floor suggested that an additional heated trolley is provided as this area of the home is divided into two separate areas and this results in one group of service users taking their meal later than others. Service users spoken to were unable to remember what meal they had ordered but do remember choosing from a selection of meals on the day previous. All service users said that the meals were good and that there was always something on the menu that they liked. Special diets are catered for and the advice of the GP or dietician is followed. The chef speaks with those service users who are on special diets and a record is held on service users files regarding favourite foods and preferences. Tables were attractively set and condiments are provided on the tables as appropriate. Meals are served to service users from the heated trolley which is placed in the dining room. The meals taken to service users in their bedrooms were not transported on trays or with plate covers, potentially leaving them open to dust. Trays and plate covers should be used for the transportation of all foods. Desserts for those service users on lighter diets were placed in the dining room prior to the heated trolley being delivered but were not covered. Food should be covered at all times to prevent contamination. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 The home has a satisfactory complaints system with evidence that service users views are listened to and acted upon. EVIDENCE: The home has a policy and a procedure to be followed in the event of a complaint being made. The complaints procedure is detailed in the Statement of Purpose and is also displayed in the home. Four complaints have been received by the home in the last twelve months and the records relating to these provide evidence that the procedure for dealing with complaints has been followed. Three complaints have been received by CSCI. All checks have been made on staff prior to them commencing work at the home to ensure that service users are protected. Staff have been given training on the different types of abuse and the action to be taken in the event of it being suspected. A copy of Wirral Borough Council’s Adult Protection Booklet is held in the home and is accessible to the staff. Service users and visitors spoken to during the inspection said they knew who to make a complaint to, would feel comfortable in expressing any concerns and were confident that any issues raised would be addressed. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 26 The standard of the décor and furnishings is good providing service users with an attractive and homely place to live. EVIDENCE: All service users are accommodated in single bedrooms, each having en-suite facilities. Some en-suites have been provided with a shower. Bedrooms were seen to be decorated and furnished to a good standard and it was evident that some service user’s families had assisted in personalising the room to reflect the personality of the service user. Some rooms were stark and bare and contain little in the way of personal items or memorabilia. Service users spoken to during the inspection said that they liked their rooms and one said that their family had provided linens to further personalise and brighten up the room. A selection of lounge areas are provided and are furnished to a good standard. Service users are free to use the communal areas of the home at any time, although some prefer to remain in their room. The staff respect service users individual preferences. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 17 The shower rooms on the first floor require some attention to bring them up to an acceptable standard. One of the shower rooms was noted to have peeling paint due to water damage where the shower curtain had been removed. No towel rail was provided and no toilet roll holder was fitted by the WC. The room smelled offensive and the shower base was stained and dirty. No lids were fitted to the bins. This room requires urgent attention. The other shower room on this floor was not fitted with a grab rail to assist service users and no toilet roll holder was fitted by the WC. The radiator in this room was damaged and had been dismantled and left on the floor. This presents as a danger to the service users, particularly as this is the EMI section of the home. This is to be attended to as a priority. The worktop in the dining room of the first floor kitchen area was extremely stained and dirty and requires cleaning. Staff spoken to confirmed that arrangements were in place for maintenance issues and repairs to be requested and that these were generally dealt with very quickly. All other areas of the home were clean and free from offensive odours. The towels used in the home were seen to be in a poor condition. Many are frayed and torn and not suitable for use. The manager and laundry staff explained that much of the damage has occurred since the new washing machines had been installed. All damaged towels should be replaced and a review of the laundry facilities undertaken. There is no suggestion that service users clothing had become damaged as a result of the laundering process. Discussion with staff identified that there was often a lack of bed linen during the busy morning period and often beds could not be made up until supplies were returned from the laundry. Sufficient bedding is to be provided. The home has an infection control policy and it was evident that staff follow the procedures laid down. Appropriate measures are in place for the disposal of waste. Discussion with the domestic staff provided evidence that all cleaning products and equipment was effective and sufficient stocks of products were held in the home. The home provides a dedicated hairdressing room and service users spoken to in this area said it was just like a real hairdressers with lots of chatting and laughter. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Continued staff training has provided service users with a high level of care through knowledge and understanding. EVIDENCE: The home employs qualified nurses and care staff to provide twenty four hour care for the service users. All prospective staff are required to complete an application form prior to being called for interview. At least two references are taken on prospective staff and checks are made through the Criminal Records Bureau and the Protection of Vulnerable Adults register to ensure the protection of the service users. The staff rotas provided evidence that the home was employing and deploying staff in accordance with the agreed number at the time of registration. The staffing within the home is reviewed by the manager on a regular basis and that consideration was being given to the provision of an additional member of staff during the busy periods as necessary. This will be reviewed regularly and amended in accordance with the needs of the service users. All new staff undertake a full induction training programme which includes Fire Prevention, Health and Safety, Moving and Handling and First Aid. The home has a training co-ordinator who is responsible for organising and providing staff training as necessary. Other recent training includes Dementia Care Mapping, Accountability, Responsibility and Record Keeping through the Royal College of Nursing. Continence Advisors provide training and Diabetes training is currently being undertaken by some staff at Chester College. Five staff have Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 19 recently completed the Manual Handlers Trainers Training course and are now able to provide accredited training to the staff. Mentorship training is being undertaken by some staff at Fazakerley Hospital. Training is being given to all qualified staff in relation to care planning and the maintenance of care files. This is being given by the manager to ensure that all staff are fully aware of the necessity to maintain the files and to provide a level of conformity within the home. A record of all training opportunities is displayed in the home and staff are encouraged to apply. Evidence of training undertaken is held on the individual staff’s files. All staff are given regular supervision and this gives the opportunity for training needs to be identified, together with a review of care practices. Considerable training has been given to all staff to ensure that a high level of care is afforded to service users. The home also employs domestic and laundry staff. Laundry staff expressed concern regarding the amount of laundry that was required to be undertaken during the weekend, when fewer staff were on duty. The laundry department attends to the laundry for Park House, which accommodates 111 service users, and also Grove House which accommodates 63 service users. The manager stated that the weekend staffing of the laundry was under review and that a new weekend laundry assistant had been recruited. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35. 38 The systems for service user consultation are good with a variety of evidence that indicates that service users; views are both sought and acted upon. EVIDENCE: The manager of the home is a qualified nurse who has considerable experience is the provision of care for older people and those who have mental health condition. He is an experienced manager who also holds teaching, assessing and mentorship qualifications. He undertook considerable management training during a previous employment with the Health Authority and was able to further his knowledge and understanding by completing an Advanced Certificate in Dementia Care Mapping. Further developmental training is planned for later this year to obtain another management qualification. Neither the home nor the company deal with any of the service users finances. Relatives or advocates are required to deal with these. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 21 The home holds Investors In People quality award and also undertakes its own quality monitoring. Service users satisfaction questionnaires have been sent out and an audit has been undertaken on meals. The manager meets with service users on a one to one basis regularly and also holds relatives clinics to enable relatives to give their views or ask questions. Reports are prepared by the Responsible Individual following monthly reviews of the home as required. A copy of the report is given to the manager and any issues raised as a result of the review are discussed and appropriate action taken. Safety certificates relating to the premises and the equipment provided were all in place and were up to date. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 4 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 4 x 4 x N/A x x 3 Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 Requirement The Registered Person must ensure that all care plans are reviewed and updated on a regular basis. The Registered Person must ensure that unnecessary risk to service users are identified and eliminated. This information is to be recorded. The Registered Person shall make suitable arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The Registered Person shall make suitable arrangements for maintaining satisfactory standards of hygiene in relation to the transportation of food. The Registered Person shall ensure that the premises are kept in a good state of repair. This is in relation to the two shower rooms on the first floor. The Registered Person shall ensure that all parts of the home are kept clean. This is in relation to the worktop on the first floor. The Registered Person must ensure that sufficient and F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Timescale for action 30th September 2005 30th September 2005 19th September 2005 2. 7 13 3. 9 13 4. 15 16 19th September 2005 19th September 2005 19th September 2005 19th September Page 24 5. 19 23 6. 19 23 7. 19 23 Emmanuel Christian Care Home Park House Version 1.40 8. 19 23 suitable towels are provided for use by service users. The Registered Person must ensure that sufficient bedding is provided. 2005 19th September 2005 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 15 Good Practice Recommendations It is recommended that an additional heated trolley is provided for service users on the first floor. Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 3rd Floor, Campbell Square 10 Duke Street Liverpool L1 5AS 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 Emmanuel Christian Care Home Park House F52 F02 Emmanuel Christian Home V248228 30_310805 Stage 4.doc Version 1.40 Page 26 - 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. 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