Inspection on 01/07/08 for Park Lane House

This inspection was carried out on 1st July 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Park Lane House 06/06/07

Park Lane House 04/01/07

Park Lane House 09/05/06

Park Lane House 15/11/05

Park Lane House 07/06/05

Park Lane House 01/02/05

Park Lane House 28/09/04

Park Lane House 31/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Park Lane House 163 Tipton Road Sedgley Dudley West Midlands DY3 1AA Lead Inspector Jon Potts Key Unannounced Inspection 9.35am 1st July 2008 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 Lane House DS0000025035.V367202.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 Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park Lane House Address 163 Tipton Road Sedgley Dudley West Midlands DY3 1AA 01902 884967 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) Mrs Amerion Merion Ramdoo Mr Raganendrano Ramdoo Stephanie Knott Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2), Old age, not falling within any of places other category (20), Physical disability over 65 years of age (2) Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 2 MD, 2 PD (E) and up to 20 OP not exceeding the total number registered for at any one time. 21st September 2007 (Random Inspection) Date of last inspection Brief Description of the Service: Park Lane House consists of a large detached house that has been extended and converted for use as a care home but is currently been extended further to provide better and additional accommodation with larger bedrooms with ensuite, larger toilets and environmental adaptations such as loop systems for use with hearing aids. The home is currently registered to accommodate 20 older people although has submitted an application to vary their registration in respect of additional bedrooms and possibly the categories of registration. The homes accessibility for residents with high physical dependencies will be improved when the building works are finished although some areas still have narrow corridors. There is no indication that the home is looking to provide a dedicated service to permanent wheelchair users and the changes made have/will make the facilities far more accessible and safer for frail older people. The Provider has installed ramps, handrails and the home does have a passenger lift. Access to the home is now via a ramp at the front of the building. The home will have car-parking facilities on the front and the back of the home when building works are complete. The home is situated on the main Tipton Road between Sedgley and Tipton, on a bus route and easily accessible by car. The home is owned and operated by two individuals who employ a manager to run the home on a day-to-day basis. The manager supervises a deputy, seniors and carers as well as ancillary staff (including cook ands housekeeper). The charges for residency in the current statement of purpose have not been updated, although the manager was in the process of producing a new statement of purpose to reflect the change in the building and is aware of the need to include the current fees levels within this. Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people that use this service experience adequate quality outcomes. This inspection was carried out over two days and was initially unannounced. The inspection was primarily focused on the key national minimum standards and evidence was collated to assess the homes compliance with the same. The inspector case tracked the care of three residents and evidence was drawn from case files, discussion with/observation of staff, sampling of management records and inspection of most areas of the home. There was also discussion with some residents and their relatives. Selected staff files, training records and health and safety records were also sampled. The residents, manager and staff are to be thanked for their ready assistance with the inspection process. What the service does well: What has improved since the last inspection? The home is, and has been in a state of flux since the last key inspection due to extensive and on –going building works. There is no doubt that management of the home during this difficult period has been and still is challenging, although it is recognised that the providers have made a significant investment that will on completion improvement the environment Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 6 dramatically and make it more service user friendly and safer. Significant changes include renovation of the heating and water system, which in the past have been problematic. There are also far better toilet facilities, which allow ample space and as a result increased privacy. In addition on completion of works there will be a reduction in the shared rooms used and many rooms are much larger and a large number have toilet and shower ensuite facilities. On completion the premises are expected to provide a far better environment for individuals living in the home. Evidence was seen that the home has addressed the requirements from the last inspection, this including some procedural improvements in staff recruitment, better documentation in respect of the providers checks on the service and specific improvements to the environment to enhance safety and privacy. The home has continued staff training input and all staff are currently undertaking dementia care training, as well as a number updating their knowledge in mandatory areas. 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. The summary of this inspection report can be made available in other formats on request. Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 4 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is currently in a period of change meaning that the information available in its current statement of purpose is out of date. The management not having admitted any residents over the last twelve months are in the process of preparing updated information that will allow prospective residents and their representatives to access information they need to choose a home that can meet their needs, this with the option of pre admission visits. The home is continually reassessing the needs of existing residents. EVIDENCE: The home has not been admitting residents due to on going building works and there have been no new admissions or re admissions of existing residents to the home in the last 12 months. Assessment of this area of practice is therefore based on outcomes from the previous key inspection, the on going assessment of individuals within the home, discussion with the manager and Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 9 sight of the homes admission policies. Discussion with the manager evidenced that she or other managerial staff would, following receipt of any referrals visit the service user and carry out an assessment to supplement any assessment provided by the social services department. It was stated that relatives /prospective residents are free to visit the home prior to any referral, and this we have seen has been the case previously with sight of copy letters to them, as well as through verbal confirmation by residents/relative to the inspector. The trial visit to the home would be for the purpose of allowing the service user to sample the service, meeting other residents and trying a meal etc. Records of these trial visits at the point of the last inspection were seen to be subject to some recording, with standardised forms devised for this purpose. It was noted that residents at the home have been involved in reviews with social services. All the case files also contained dependency assessments that staff have reviewed monthly, these in conjunction with the care plan giving a clear picture of residents current dependencies. We discussed the current statement of purpose and resident’s guide with the manager in respect of a draft copy we were sent to us by the home. The manager stated that she is still working on these and is looking to provide a more pictorial orientated document with photos of the home completed, this not possible at present though as the building works are still in progress. The manager indicated that the updated information would hopefully be available at the point they were looking to commence admissions to the home, and was aware of the need to include updated fee information within this. Contracts were in place for all residents whose case files were examined, these signed by representatives. These set out basic information on what residents can expect to receive for the fee they pay and also sets out terms and conditions of residency. Some revision to this contract has been made to clarify who has responsibility when relatives take individuals out without staff accompanying them. Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care, which a resident receives, is based on their individual needs. Care plans reflect resident choices and needs underlining their involvement in putting these together. The principals of respect dignity and privacy are put into practice; this assisted by improvement to the environment. EVIDENCE: The service involves individuals in the planning of care that affects their lifestyle and quality of life this evidenced through discussion with them and evidence of their agreement through signature on the plans. Plans were seen to be reviewed on a monthly basis, with updates based on any changes to need. The plans include information as to the full range of the individuals care needs whether they are physical, social or emotional with health needs clearly detailed, this building on the homes assessments and dependency profiles. Tracking of the information in the plans in comparison with information Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 11 provided by residents and others we spoke to (as well as documented in other records) showed that the plans were accurate and the plan of care detailed was actually provided by the service. Comparison of the care plans with information from the last multi disciplinary reviews showed that individual’s needs were been met. Residents and relatives told us that they receive the care and support that they need from staff. Residents have access to all community health care services as needed and as identified within care plans, this including GPs, district nursing, chiropody, dentists, opticians and chiropody. The aims and objectives of the home reinforce the importance of treating individuals with respect and dignity. There was clear evidence of the home maintaining health care treatment and intervention in respect of tissue viability and nutrition, this including weight monitoring. Weight records showed that three of the residents have gained weight slightly in the last six months, this monitored through use of sit on scales that were seen to have been calibrated. There was evidence that incontinence assessments have been carried out by district nurses with the regime for the management of incontinence pad usage documented within care plans, this information that staff were also fully aware of. The home has an appropriate medication policy and procedures and we saw that medication records are fully completed, contain required entries, and are signed by appropriate staff. None of the current residents chose to self medicate although the home has previously been known to allow residents self-administration within a risk assessment framework. The home has safe facilities for keeping medication, including controlled drugs, although the medical wall cabinet does need to be secured to a wall, having been temporarily removed due to the homes renovation. The home practices in respect of the receipt, administration, safekeeping, and disposal of Controlled Drugs were found to be acceptable. Staff who administer medication have completed and passed an appropriate medication course. We saw that the manager carries out assessments (this as part of the supervisory process) to ensure each member of staff is competent to handle, record and administer medication properly. Staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care, this seen to be the case through discussion with staff and observation of the care staff’s involvement with residents. We were told staff allow residents access to privacy and when wished they are able to enjoy this by spending time in their own rooms. Residents were clear that the staff did not compromise their independence and they were encouraged to carry out tasks for themselves wherever possible, this reflected in care plans. Current developments will lead to a reduction in Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 12 the number of shared rooms, none of these in current use however. Of note are the changes to the toilets in the home, which now provide more space and allow privacy that was not attainable previously due to their size. One resident spoken to was concerned as to their not having a bedroom key, although the manager did state that when they moved back to their designated room (which was currently been refurbished) a key would be provided. Where residents are unable to hold keys risk assessments have been completed to identify why this is the case. Park Lane House DS0000025035.V367202.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices about their life style that are respected by staff. The availability of social, educational, cultural and recreational activities for residents has decreased over the last year, this an area the manager has identified as needing improvement. Residents have access to a choice of meals that provide nutrition and are enjoyable. EVIDENCE: Staff are aware of the need to plan routines and activities around the wishes of the residents and there was documentation in case files to show that there had been consultation with residents around what these wishes were, with choices documented confirmed as accurate by the individual resident. Discussion with residents and observation showed that staff provided some flexibility in the way they provided care to meet with residents wishes, this in accordance with care plans and as supported by the homes policies and procedures. There was some documentation of residents preferences in respect of activities documented in case files, although there was no activities programme Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 14 displayed in the home due to on going redecoration. Individual records in respect of those residents whose care was tracked showed that some activities were offered in accordance with the wishes of those residents spoken to although the manager did state that these are limited to a degree due to the small number of residents and on going building work. An example of this is where the local church, which was visiting on a monthly basis, has ceased its visits due to the small catchment group. They have agreed to reinstate these visits when the home has more residents. Community access was also limited, with residents only going out with relatives. Current staffing levels would not allow for them to take residents out, although the staff during the course of the day were seen to be trying hard to stimulate the residents with discussion and a variation of ‘I-spy’. This area is one the manger was conscious needs to be improved in conjunction with the homes overall development. Based on the last inspection showing that the home was performing well in this area it is expected that this will be achieved. The home has open visiting arrangements up to 8pm, the only restriction to avoid meal times, and residents are able to entertain their friends and visitors in their rooms if they wish (as was seen). There is only one available communal area at present although this is a temporary arrangement until the other 2-lounges/dining area are ready for occupation. Visitors were seen at the home during the course of the day and we saw staff make them welcome and offer them drinks. Relatives have told us that they are kept up to date with developments by staff. Residents were seen to be able to have their own personal possessions in their rooms within health and safety or space considerations. There was documented evidence of some residents or their representatives been made aware of their right to access records or information held about them by the home. Whilst we saw that there were statements as to the residents mental capacity to make decisions in case files there was no assessments in place to verify how this decision was made and the manager was advised to obtained a copy of the national guidelines relating to the mental capacity act. The food in the home was seen to be of good quality, well presented and meeting the dietary needs of the residents. The food records, whilst not consistently completed showed that a varied diet was available consisting of foods that met residents cultural preferences. Staff consult with residents as to their choices and preferences in respect of meals on a daily basis and are able to offer choices, as we saw was the case, these choices consistent with those recorded in the care plans. Residents confirmed that the food was ‘lovely’ and when we sampled the meal of the day we found this to be easy to digest, tasty and well presented. Comment from a relative was that ‘My mom seems to enjoy the meals and leaves little’. Park Lane House DS0000025035.V367202.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have confidence that these will be listened and responded to. Management and staff are aware of what constitutes abuse and the necessary steps that should be taken to prevent it. EVIDENCE: The service has a complaints procedure that meets the national minimum standards and regulations. The complaints procedure, whilst not currently available on display (as there was redecoration on – going), is known to residents and relatives. The manager did state that she is looking to develop a pictorial version of this procedure so as to assist easier understanding. There is information as to how to complain in the terms and conditions of residency. Residents and relatives told us that they knew who to speak to if unhappy and ‘Any comment made to staff and management is immediately dealt with’. Staff were said to listen to the residents and also act upon what was said. The home has not received any complaints over the last 12 months. We did however view the complaints log and there was evidence that any complaints received are fully documented and outcomes recorded. Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 16 We saw that based on comments in a multidisciplinary review the provider was said to be managing the finances for one of the residents. When requested that manager told us that no records of how this resident’s finances were managed were available at the home. The provider has however made these records available and we saw that they were recorded appropriately and records matched the actual amount of monies available. The provider stated that monies are not kept on site at present due to the current building works, although this would change at the point these were completed. In addition the provider stated that she was trying to encourage the resident to open a building society account for safekeeping, this as she felt it would be safer for the resident and the home. We were told that at present there are no other resident’s monies in safekeeping, these managed by relatives. The home has access to the local authorities vulnerable adult procedures and the manager and staff were aware of the steps to take if witnessing abuse. Training in adult protection has been provided to staff with updates of this training planned in the near future, this through the local social services training centre. The majority of the staff team are currently undertaking an accredited distance-learning course in dementia care. Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is currently in the process of extensive refurbishment that will improve its physical design and layout, providing residents with a better living environment. There are some issues that have the potential to compromise the safety of the residents however. EVIDENCE: The home is currently undergoing an extensive redecoration and refurbishment programme that has involved a large extension to the home. Whilst it is difficult to fully assess the facilities as they will be post completion a tour of the property as it stands showed that there is much improvement in that there is now a new heating system (with low surface temperature radiators), many ensuite rooms (including floor level showers) many which are Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 18 very spacious, larger adapted toilets, ramped access to the front of the building and handrails within the new extension. The four residents still living at the home are currently using one of the existing lounges and this provides an environment that allows residents to be separate from the building work, although there was decoration in progress in the corridor outside of this area on the day of the visit. One resident told us that there is little noise from the builders although another did comment that ‘I don’t like it here anymore’ and indicated this was due to the changes in the environment. Staff and the manager were aware of the anxiety that the changes have caused for residents and risk assessments in individual’s files have focused on how to keep residents safe and alleviate anxiety. Another resident did however comment that she had enjoyed seeing the changes take place from their bedroom window. The residents are currently using bedrooms at the rear of the building, these some distance from the hub of the building work and as a result safer. We sampled the servicing certificates for equipment in use at the home and these with the exception of the following were found to be in place: • Checks of the emergency lighting and fire alarm had not been carried out since 22/4/08. In addition whilst there are risk assessments in place, in light of the on going building works and on going changes more regular review of these would seem advisable, especially in respect of fire safety. The use of such as tick lists to evidence on going audits of the environment to ensure that it is safe was suggested although the manager was advised to seek advice from such as the Fire Prevention Officer and Environmental services. The home was seen to be well lit, clean and tidy (in those areas the residents were using). The management has a reasonable infection control policy and they have been known to seek advice from external specialists, such as the health protection agency in response to outbreaks of infection. Staff have mostly received training in infection control and updates are planned for the near future. Liquid soap and paper towels were seen to be available for staff use as was protective wear such as gloves and aprons, these seen to be used by staff whilst carrying out personal care. The manager stated that work is planned to renovate the laundry (currently based in the cellar) so that it is easier to clean, fitted with better equipment etc, within the next phase of building work. In discussion staff were aware of the temperatures necessary for washing of soiled laundry. Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is generally sufficient staff hours available to fulfil the aims of the home and meet the changing needs of residents although staff deployment could be better at times, with staff not working in accordance with the stated expectations of the manager. Training in mandatory areas was seen to be well managed and insight into developing training targets based on residents needs is good. EVIDENCE: People using services told us they were satisfied that the care they receive to meet their needs, and all residents and relatives spoken to were positive as to the attitude of staff and their approach. There were generally sufficient staffing levels at the time of the inspection, although there are some concerns as to the deployment on occasions. The manager told us that one of the care staff on the morning shift would be denoted as the cook, leaving the other carer and the cleaner/carer to be available to residents, with one based in the lounge. This was not the case on the morning of the visit with both staff in the kitchen and the domestic/carer involved in cleaning. The manager was advised that she needs to ensure that staff are available for residents in the lounge (as requested by relatives during consultation meetings). This would ensure that the home was able to meet the risk assessments in respect of reducing the risk Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 20 to residents from on going building work. In addition the manager was advised to clarify in the rota when the domestic/carer was to provide care and when to clean to ensure adequate cover, and if necessary provide additional time for cleaning duties. The recording of the exact hours the night staff work would also assist clarity. Deployment of the staff during the afternoon of was better and also on the 2nd occasion we visited the home. The service recognises the importance of training, and the manager is working hard to deliver a programme that meets any statutory requirements and the National Minimum Standards, this with some success as the majority of staff have training in the majority of mandatory areas and the manager is looking to provide updates to these. The manager is getting better at recognising when additional training is needed, and based on her comments is able to source specialist training providers to assist with the provision of this training. At the point of the inspection nearly 100 of the staff held an NVQ 2 or/and 3 qualification in care and the majority of staff are also undertaking an accredited course in dementia care. Staff spoken to told us they were well supported with training that they felt was appropriate and kept they up the date with changes in the way they worked. People using the service told us that their needs were met by staff although there was some differing views as to whether there was sufficient staff, this possibly due to deployment issues as mentioned above. Outcomes of reviews with social services also indicated that resident’s needs were being met. The service has not recruited any new staff in over a year so there was no current evidence of recruitment practice though based on discussion with the manager she was well aware of the steps she needed to take to ensure that this was carried out in a manner that ensured residents were protected. Sight of staff files showed that all necessary records were available within them including enhanced disclosures. The service does however need to be aware that enhanced disclosures must be destroyed after they have been used for the purpose they were obtained for (i.e. to evidence suitable checks on staff). A record of the disclosure number and the date obtained should be retained in the staff file for reference however. Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 & 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The management and administration of the home is developing with evidence of greater proactively with the introduction of tools that will assist in self-audit, although these need to be maintained. Issues in respect of health and safety of residents need to be risk assessed more robustly to ensure residents any hazards are identified. EVIDENCE: The manager is now qualified to NVQ level 4 and has now secured funding for commencement of her Registered Managers Award, this she said she will commence shortly. She also has extensive experience of running the home at management level and from discussion it was clear that her awareness of the Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 22 basic processes set out in the National Minimum Standards and of good practice is improving. The manager stated that she was well supported by the homes provider with weekly meetings, (these seen to be fully documented) where any issues arising could be discussed, and where there was support available to her. The financing of the business is the responsibility of the provider although the manager is involved with this through the business planning for the home, with clear, and simple business objectives set for the forthcoming year, a number of these with a customer focus. The home has purchased policies and procedures “off the shelf” these in general satisfying the basic minimum requirements of the regulations and national minimum standards, although the manager said that she is in the process of reviewing all of these, this in some part dependent on the direction the home takes following completion of building works and the content of the application to vary the home registration that has been submitted to us. We discussed how an emphasis on equality and diversity within the review of policies (including how opportunities are promoted for residents that maybe disadvantaged) would be useful, this in conjunction with staff training in this area. Quality assurance monitoring is based on use of a tool that has a basis on regulations and national standards. The evidence used within this tool is drawn from an audit of the standards by the management. The provider as stated has weekly meetings with the manager and staff felt able to approach the former if needed. It was stated that the providers call in unannounced on a regular basis and the manager told us that a summary of these visits into a monthly report was to carried out in future. Whilst there have been no recent questionnaires completed by residents, relatives and stakeholders we are conscious that there is at the time of writing only a small number of residents at the home, and there was clear evidence that there has been on going consultation between the providers, manager, residents and relatives through three monthly meetings where any developments in respect of the on going development of the home have been discussed and concerns listened to. We discussed the Annual Quality Assurance Questionnaire (AQAA) with the manager. All sections of the AQAA were completed and the information gave a reasonable picture of the current situation within the service although there are areas where more supporting evidence would have been useful to illustrate what the service has done in the last year, or how it is planning to improve. The manager has received limited guidance in completing this documented and told us how she intended to source information on completing the AQAA. We suggested that the quality assurance system, which should be a tool that is used on an on going basis, should assist in identifying information to include in the AQAA, with findings from this tool then summarised in the latter document. Staff in discussion did show an understanding of key issues, and had an awareness of where the policy/procedure folder was kept for reference. Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 23 The last few staff meetings have taken place three monthly, the provider available for these. Supervision sessions are regular and staff find them helpful, with these sessions been based on the manager or seniors observing staff practice then having a one to one session to discuss the observation or discussion around the homes procedures. Notes are taken of meetings and sessions. We saw that resident’s property is clearly documented within inventories and sampling of these showed that they were accurate. Records in respect of the monies held on behalf of one resident were seen and judged to be appropriate. The home has a health and safety policy with the majority of mandatory health and safety training delivered or planned, this with a few exceptions. The last Environmental Health Visit to look at food safety (September 2007) stated that they were “ Overall pleased with overall standard of premises”. The one issue that had been raised had been addressed. There are some issues in respect of the environment section of this report that should be note however, this in respect of more robust risk assessment, and ensuring that the fire equipment is checked on a regular basis. Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 24 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 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP14 OP16 OP18 OP27 Good Practice Recommendations The registered manager should obtain a copy of the mental capacity act code of practice for use by staff in the home. To develop the homes complaints procedure in large print and pictorial format. To display the photos of all staff in a communal area so as to assist residents and relatives to identify them by name. The registered manager and provider should ensure that staff are consistently deployed in a manner that allows risk assessments in respect of residents safety during the progression of building work to be fully met. The registered provider manager must ensure that all staff continue to read, sign and date all written policies and procedures operational within the home; this after they have been reviewed so as to ensure they match the homes individual and specific practices. The registered persons should review the homes policies in DS0000025035.V367202.R01.S.doc Version 5.2 Page 26 5. OP31 6. OP32 Park Lane House 7. OP38 respect of Equality and Diversity and how opportunities are promoted for residents that maybe disadvantaged. The registered manager/providers should discuss with the Fire Prevention officers ways in which the fire risk assessment for the home can be managed in light of on going changes to the building, also ensuring that on going checks in respect of fire safety equipment and staff awareness of current fire safety arrangements are accurate. In addition all risk assessments in respect of safe working practices should be reviewed and expanded so that they cover all areas of potential risk to service users, staff and visitors to the home. Park Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Lane House DS0000025035.V367202.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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