Inspection on 23/08/06 for Park House Nursing Home

This inspection was carried out on 23rd August 2006.

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

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

Other inspections for this house

Park House Nursing Home 29/04/08

Park House Nursing Home 20/07/07

Park House Nursing Home 14/12/05

Park House Nursing Home 22/06/05

Park House Nursing Home 18/11/04

Park House Nursing Home 22/07/04

Park House Nursing Home 05/02/04

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Hawkhills

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Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Park House Nursing Home Park Lane Queensbury Bradford BD13 1QJ Lead Inspector Mary Bentley Key Unannounced Inspection 09:30a 23 & 25th August 2006 rd 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 Nursing Home DS0000029237.V298174.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 House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park House Nursing Home Address Park Lane Queensbury Bradford BD13 1QJ 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) 01274 817014 01274 884514 Kloriann Medicare Ltd Mrs Helen Patricia Harrison Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability (1), Terminally ill over of places 65 years of age (3) Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for PD is specifically for the service user named in the application for variation dated 20 May 2005 14th December 2005 Date of last inspection Brief Description of the Service: Park House is a converted Victorian house set in its own grounds and situated near the village of Queensbury. The home has well maintained gardens that include a woodland walk, and are accessible to service users. There is wheelchair access to a patio area from one of the lounges. The home offers nursing care to male and female service users over the age of 65 and provides three places for the care of people with terminal illnesses. Park House provides accommodation in seven double and nine single rooms, a number of rooms have en-suite toilets. Many of the rooms in the old part of the house have excellent views of the gardens. The home has 2 lounges, a dining room, conservatory, and a small seating area on the second floor. The standard of décor is good. The home has a no smoking policy. Weekly fees range from £500.00 to £530.00. Additional services such as hairdressing and private telephones are not included in the fees. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate”, and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The last inspection was done in December 2005 and there have not been any additional visits to the home since then. The purpose of this inspection was to inspect all the key standards, (the key standards are identified in the main body of the report), to assess how the needs of people living in the home are being met. The methods used in this inspection included looking at care records and other paperwork such as staff and maintenance records, talking to residents, staff and management, observing care practices in the home and looking at all parts of the home. The home completed a pre-inspection questionnaire and the information provided was used as part of the inspection. The inspection was unannounced; it was carried out on 23rd and 25th August 2006 by one inspector. On 23rd August the inspector was in the home between the hours of 9.30 am and 4.30 pm and on 25th August between the hours of 9.30 am and 1.00pm. Feedback was given to the manager at the end of the visit. Comment cards were sent to a number of residents and relatives before the inspection. These provide people with an opportunity to share their views of the service with the CSCI. Information obtained in this way is discussed with the home without identifying who has provided it. Residents and relatives returned fourteen comment cards; their feedback has been included in the relevant sections of this report. Comment cards were also sent to a number of GP practices, two were returned, and showed that they are satisfied with the service. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose must be reviewed and kept up to date so that residents have clear written information about the range of services and facilities being offered. Residents health care needs are met, however improvements must be made to the care records to make sure that care needs are not overlooked Residents’ views of the food varied and more attention must be given to the provision of snacks between meals, particularly between the evening meal and breakfast. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 7 Despite the fact that the environment is lovely and well maintained there are a number of shortfalls that limits residents’ choices and privacy, specifically these refer to the provision of communal bathrooms, door locks, and facilities for communal hairdressing. Thirteen requirements and a number of recommendations have been made about these and other issues identified in the report. 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 Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 8 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 Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5. Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents and relatives said they had been given enough information before choosing the home. However, despite the fact that people are given good verbal information this is not supported by up to date written information. Prospective residents and/or their representatives are given the opportunity to visit the home before admission and residents are not admitted until their needs have been assessed. EVIDENCE: Pre admission assessments were seen in two sets of care records and contained good detail. Residents and/or their families are encouraged to visit the home before making a decision about admission. One resident had visited the home before moving in, she had chosen her room and was pleased with it. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 10 Relatives of two residents said they had chosen Park House after looking at several other homes. One had particularly noticed the cleanliness of the home and the absence of unpleasant smells, the other was impressed because they had visited unannounced and had been shown everything, including the laundry, and this reassured them that the home had nothing to hide. Both felt they had chosen well and were satisfied that their relatives were being well cared for. The Statement of Purpose is not up to date and does not contain all the required information; this has been raised at previous inspections. For example it does not include a schedule of room sizes, does not refer to the limited number of bathing facilities and does make it clear that many bedrooms do not have door locks fitted. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 11 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, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Overall the health and personal care needs of residents are met. However in order to make sure that appropriate care is delivered consistently and care needs are not overlooked the home must address the shortfalls in the care records. Residents are protected by the homes’ systems for dealing with medicines. EVIDENCE: Three sets of care plans were looked at. The care plans address how personal; health and social care needs will be met, some in more detail than others. The purpose of the care plan is to set out in detail how individual needs will be met and good care plans should show residents’ abilities as well as areas of need, phrases such as “a good wash” and “adequate fluids” do not provide clear instructions for staff. Discussions with care staff suggested that they do not really use the care plans and rely on the reports given at shift handovers Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 12 for information on residents needs. This creates the opportunity for residents needs to be overlooked. Residents and relatives said they were consulted about how care needs would be met although this was not always reflected in the care plans. Risk assessments were completed relating to pressure sores, nutrition and falls and although care plans had been put in place they did not always provide enough detail about how the risk would be managed. For example one resident had an identified problem with weight loss but the care plan did not give details on how to deal with this, there was no information on food preferences and no reference to offering snacks between meals. Two residents in the home have pressure sores, the Tissue Viability nurse has been consulted about the treatment plan, and this is good practice. The records showed that residents have access to a range of health and social care professionals and residents said they received the medical support they needed. One GP said it was an “excellent” home. There was little or no information in the care plans about residents wishes in relation to end of life care, the manager is aware that this is an area that needs to be addressed. The arrangements for dealing with medicines are satisfactory; none of the residents in the home at the time of the inspection were administering their own medicines. Staff are kind and respectful, two regular visitors commented on this, one said “residents are treated with respect” and other said “staff look after the residents as individuals”. The absence of door locks potentially compromises residents’ privacy, more detail is provided in the environment section of this report. The home must also look at how they can provide alternative facilities for the hairdresser as communal hairdressing is currently done in a residents’ bedroom. It is acknowledged that the representatives of the residents who currently occupy this room have been consulted and have no objection to this practice. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Daily routines are reasonably flexible, residents are encouraged to keep in contact with family and friends, and the home is very welcoming to visitors. There are some opportunities for residents to take part in social and leisure activities however more attention must be given to providing residents with regular opportunities to take part in social and leisure activities that reflect their preferences and expectations. The majority of residents said they usually liked the food. Despite the fact that the home has put a supper menu in place many residents said they were only offered drinks between the evening meal and breakfast. EVIDENCE: The activities offered include dominoes; bingo, videos, exercise sessions, coffee mornings, and outside entertainers visit the home on a regular basis. However the social care plans contained very little specific information about residents’ individual preferences and abilities. Although a lot this information is available it is not used to devise individual social care plans, for example one Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 14 resident spends an afternoon at home every week but this was not mentioned in her social care plan. Residents who are unable to go out with family or friends for whatever reason have very little opportunity to take part in social events outside the home. Both residents and staff felt that more could be done to meet social care needs. The manager is aware that this aspect of the service needs to be developed. Daily routines are flexible and residents get up and go to bed when they choose. Some residents choose not to use the communal areas and spend most of their time in their rooms; meals are served to residents in their bedrooms if that is what they prefer. There are no restrictions on visiting, relatives said they are always welcome and confirmed that visits can take place in private. One person said “As a visitor I am always made welcome and am kept up to date with my relatives well being” There is some awareness of diversity and equality but this tends to focus on religious needs. Ministers from the local Church of England and Catholic churches hold services in the home and some residents have private visits from church representatives. A resident of Polish origin has family and friends who visit and bring “special” food. There was a mixed response from residents as to whether or not they liked the food, one person they always liked it, but others said it varied. One resident said, “breakfast and lunch are ok, tea is usually soup and malt bread, not enough to go through from 4.30 until 9.00 the next morning”. Another resident said she had not eaten all the mashed potato at lunchtime because it was dry and there was not enough parsley sauce to mix with it. Although the home has recently consulted residents about the teatime menu and has put a supper menu in place, (supper is usually served at 7.00pm) there was conflicting information about what food was provided after teatime. Staff said residents were offered toast or cake at 7.00pm but all the residents spoken to said they were offered a drink and occasionally a biscuit. Some residents said they kept their own biscuits to have at suppertime. The manager said there was information in the kitchen about residents dietary preferences and needs but the cook on duty on the first day of the visit did not appear to be aware of this and said staff remember residents’ likes and dislikes. She had a fairly limited knowledge of residents’ special dietary requirements. She was aware of which residents needed diabetic or soft diets and identified some residents as needing a more nourishing diet. However two of care plans looked at identified special dietary requirements, one for a high fibre diet and the other to address weight loss and she was not aware of either of these. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 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 the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home has the required policies and procedures in place to make sure that complaints are dealt with appropriately and that residents are protected from abuse. EVIDENCE: The complaints’ procedure is displayed in the home. The home has not had any complaints since the last inspection and none have been received by the CSCI. Four of the seven residents who completed comment cards said they were aware of whom to speak to if they were unhappy and five said staff listen to them and act on what they say. Five of the seven relatives who completed comment cards said they were aware of the complaints’ procedure. The majority of staff have attended Adult Protection training run by Bradford Social Services, training is being arranged for three new members of staff. Staff have a good understanding of what constitutes abuse and know how to report concerns, both inside the home and to external agencies. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 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 the following standard(s): 19, 20, 21, 22, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Park House provides a very pleasant, clean, and comfortable environment. However there are some shortfalls in the environment that potentially limit residents’ choices and privacy. The main concerns are that there are only two assisted bathrooms and many of the bedrooms do not have door locks fitted. EVIDENCE: All parts of the home are decorated and furnished to a high standard. The home was clean and there were no unpleasant odours. One relative said, “The home is well maintained, always clean and well presented”. There is an ongoing programme of maintenance and at the time of the visit the dining room was being refurbished. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 17 The conservatory gives residents an excellent view of the gardens and the bird tables. There is a patio with garden furniture that residents can use, weather permitting. There has been no change to the provision of communal bathrooms since the last inspection. The top floor bathroom has been taken out of use leaving two assisted bathrooms. This is less than the home provided when the National Minimum Standards were introduced in 2002 and falls short of the recommended ratio of one bathroom for every eight residents. Residents said they have a bath once a week. The home has converted one large double room to create two single rooms, the new rooms are very nice however door locks, and radiator guards have not been provided. Thermostatic valves are fitted to hot water outlets to control the temperature, however the home does not keep a record of checks carried out on hot water temperatures. These checks are necessary to make sure that the valves are working effectively and the temperature is maintained close to 43 degrees C. Despite assurances given to the CSCI last year a tour of the home showed that several of the bedrooms do not have door locks. An inappropriate lock was fitted to one bedroom door, which meant that the resident had to ask staff to lock and unlock the door when she was not in the room. Some bedrooms provide a fire escape route for other bedrooms; door locks that are released by the fire alarm system will have to be fitted to these rooms. In the interim consultation should take place with residents regarding the implications for their privacy. In most of the rooms seen residents had some of their personal belongings around them. Screens were provided in all shared rooms. Some concerns about working practices in relation to control of infection were identified. These related to the identification of personal toiletries in shared rooms, the storage of different coloured cleaning cloths in one container while in use, and the use of gloves by housekeeping staff. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 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 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents and relatives spoke very highly of the staff and generally were satisfied that there were enough staff to meet peoples’ needs in a timely way. Since the last inspection the manager has made a lot of progress with staff training and development thereby making sure that staff have the necessary skills and knowledge to meet residents’ needs. Robust recruitment procedures are now in place to make sure that residents are protected. EVIDENCE: The home lost a lot of staff in the early part of this year; this was as a result of checks on the immigration status of staff, which identified a number of people who were not eligible to work in the U.K. This inevitably caused some disruption and an unusually high use of agency staff. New staff have now been recruited and the manager is confident that the home can look forward to a period of stability. The manager is to be commended for the way she dealt with this very difficult issue. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 19 One relative commented that the home now seemed to have more permanent staff and was not using as many agency workers. Residents’ views of the availability of staff varied, most people said staff were usually available when needed. One resident said staff were “always too busy” and another said, “If I ask for something they say they will come back, some do and some don’t”. Relatives spoke highly of the staff describing them as “friendly” “cheerful” “caring” and “professional”, one person said, “ I have nothing but praise for both staff and management” Two staff files were looked at and showed that all the required preemployment checks are completed before new staff start work in the home. Information provided by the home showed that 50 of care staff are qualified to NVQ (National Vocational Qualification) level 2 or above, this meets the recommendations of the National Minimum Standards. Training records are now available for all staff and this includes a record of induction. One member of staff gave a good account of the induction training she had received when she started work at the home. She said she had been made very welcome and all staff work together as a team. The home has a trained moving and handling co-ordinator and all staff are up to date with this training. Fire training is up to date for the majority of staff and a training session is scheduled for those staff that have not yet attended. Staff are now paid for mandatory training and as a result attendance has improved. Training has also been provided on falls prevention, diet and nutrition and Adult Protection, training on infection control is planned. The manager is in the process of doing staff appraisals and has set up a system for staff supervision; all staff have had at least one supervision. The manager is planning to delegate some staff supervision to nursing staff when they have received the appropriate training. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 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 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The manager offers strong leadership; staff are supported in their roles and although the quality assurance systems are still being developed residents and/or their representatives are encouraged to share their views of the service. There are some shortfalls in relation to health and safety, which potentially expose residents and staff to unnecessary risks. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager is a nurse and has many years experience in the care of older people. Since the last inspection the manager has been registered with the CSCI. In September 2006 she is starting the Registered Managers Award, she has to complete 3 units to supplement her existing qualification. Residents and relatives felt the management team were approachable and staff said they felt supported in their roles. One person said, “Park House is a welcoming and well run establishment”. The manager is working on developing a quality assurance system, she will have more time to devote to this later in the year when her supernumerary time increases to four days a week. She is devising questionnaires to send to residents and relatives. Relatives confirmed that they are consulted and kept informed, however at the moment very little of this is recorded. Monthly audits of care plans, medication and pressure sores are in place and the manager is developing formats to audit other aspects of the service such as infection control, catering, and laundry. There have been two staff meetings since the last inspection. One meeting for residents has taken place; this was mainly to discuss menus. The manager plans to hold residents’ meetings about three times a year. The administrator was on leave at the time of this visit. The owner confirmed that there has been no change to the systems for dealing with residents’ finances since the last inspection. There is a long-standing arrangement whereby the home acts as appointee for two residents. This came about because of exceptional circumstances. Neither of these residents receives a personal allowance and any additional services they require, such as hairdressing, are paid for by the home. The home no longer takes on the responsibility for managing residents finances. For the remaining residents the home issues invoices for additional services such as hairdressing and/or newspapers. None of the residents in the home manage their own finances. The records showed that the required checks on the fire safety systems are carried out and the manager is working on dealing with the issues identified in the recent fire safety report. The gas safety certificate (Landlords certificate) was not available at the time of the inspection. Tests on portable electrical appliances were overdue. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 22 Some other health and safety issues relating to radiator guards and checks on hot water temperatures are detailed in the environment section of this report. A new risk assessment for the use of bed rails and protectors has been implemented. The use of bed rails throughout the home should be reviewed, as there appeared to be a very large number in use. The manager is currently responsible for bed rails and is well aware of the potential hazards associated with their use. The accident records were satisfactory, the manager is aware that the present format is not suitable because records cannot be stored individually to comply with Data Protection law. She is planning to introduce a new format. Accident monitoring done by the home showed a reduction in the number of falls. Park House Nursing Home DS0000029237.V298174.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 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 3 X 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 2 2 Park House Nursing Home DS0000029237.V298174.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 OP1 Regulation 4 Sch.1 Requirement The Statement of Purpose must include details of the number and sizes of rooms in the home. Previous timescales of 29/10/04, 25/02/05,31/08/05, and 31/03/06 not met. The Statement of Purpose must be reviewed and kept up to date and must accurately reflect the services and facilities provided. The CSCI must be provided with a copy of the updated Statement of Purpose. Previous timescale of 31/08/05 & 31/03/06 not met. Each resident must have a 24/11/06 detailed plan of care setting out how their assessed needs will be met in relation to personal, health and social care. The registered persons must provide a programme of activities that reflects the needs, capabilities and preferences of residents. DS0000029237.V298174.R01.S.doc Timescale for action 24/11/06 2 OP1 4 24/11/06 3 OP7 15 4 OP12 16(2) 24/11/06 Park House Nursing Home Version 5.2 Page 25 5 OP15 16(2) The registered persons must make sure that residents have a varied and nutritious diet that meets their assessed needs and takes account of their dietary preferences. The interval between meals, including snack meals, must not be longer than 12 hours. The registered persons must make sure that there are enough baths/showers to meet the needs of residents. Previous timescales of 25/03/05, 26/10/05, & 31/03/06 not met. 27/10/06 6 OP21 23(2)(j) 15/12/06 7 OP24 12 Door locks must be provided on all bedroom doors and residents must be provided with a key to their room unless there is a documented risk assessment indicating the reasons why this would not be appropriate. Previous timescale of 1/12/04 not met. Bedrooms that are fire exists must have door locks that are automatically released when the fire alarm is activated. The radiators in the new bedrooms must have guards fitted or be replaced by low surface temperature radiators. The registered persons must check hot water temperatures to make sure that the valves are working properly and temperatures are being maintained as close to 430 C as possible. The registered persons must make sure that staff adhere to safe working practices to reduce the risk of cross infection. DS0000029237.V298174.R01.S.doc 15/12/06 8 OP25 13(4) 24/11/06 9 OP25 13(4) 24/11/06 10 OP26 13(3) 24/11/06 Park House Nursing Home Version 5.2 Page 26 11 OP33 24 The registered persons must establish and maintain a system for evaluating the quality of the services provided at the home. They must provide the CSCI with a report which describes the extent to which, in their reasonable opinion, the home a) Provides good quality services and b) Takes account of the views of service users and their representatives on what services are to offered and the manner in which they are to be provided. The report must include details of any measures the registered persons are going to take to improve the quality and delivery of services. A copy of the gas safety certificate (Landlords certificate) must be sent to the CSCI. Tests on portable electrical appliances must be done at least once a year. New electrical appliances must be tested before they are put into use. 31/01/07 12 13 OP38 OP38 13(4) 13(4) 27/10/06 27/10/06 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 home should, within reason, be able to comply with residents’ wishes with regard to how often they have a bath. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 27 2 3 4 OP10 OP30 OP38 The home should consider providing an alternative hairdressing facility so that it is not necessary to use residents’ bedrooms to provide communal services. The home should implement the Skills for Care induction standards. The use of bed rails throughout the home should be reviewed to make sure that they are only being used in response to an identified risk. Park House Nursing Home DS0000029237.V298174.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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