Inspection on 15/11/05 for Park Lane House

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Lane House 01/07/08

Park Lane House 06/06/07

Park Lane House 04/01/07

Park Lane House 09/05/06

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Park Lane House 163 Tipton Road Sedgley Dudley West Midlands DY3 1AA Lead Inspector Debbie Sharman Unannounced Inspection 15th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Park Lane House Address 163 Tipton Road Sedgley Dudley West Midlands DY3 1AA 01902 884967 NONE 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 Mrs Amerion Merion Ramdoo 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.V266441.R01.S.doc Version 5.0 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. 8th July 2005 Date of last inspection Brief Description of the Service: Park Lane House consists of a large detached house that has been extended and converted into a residential home. The home can accommodate 20 elderly residents in 16 single and 2 double bedrooms. The home has two large lounges and a large dining room. The home was found to be pleasantly decorated and homely. The home can take service users who have low to medium dependency needs as a result of problems with access to some parts of the home that would be experienced by heavily dependent and wheelchair service users. The home does have a passenger lift. However, there remain some bedrooms that can only be accessed by steps. Access to WCs would be problematic to wheelchair dependent service users. The Proprietor/Manager have installed ramps, handrails. The home has a level well-maintained garden on the side of the home, which incorporates ample car parking facilities. The home is situated on the main Tipton Road between Sedgley and Tipton. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection meaning that neither the proprietors, staff nor residents received prior notification and were not able to prepare. An Inspector and a pharmacy Inspector conducted the Inspection. The plan for the inspection was to assess those key standards, which were not assessed at the previous inspection and progress towards related previous requirements. The pharmacy Inspector was to inspect medication including progress made towards addressing concerns he had brought to the registered person’s attention at his previous inspection on July 8th 2005. The pharmacy Inspectors reports and requirements for improvement are available separately to this report. It was also planned to reassess recruitment of new staff processes given that there were concerns at the previous inspection about the homes ability to protect service users when recruiting new staff. New staff have not been externally recruited since the last inspection so it was not possible to fully judge performance at this inspection. Documentation was assessed and the Inspector was able to interview a service user and his relatives about the performance of the home. A second visiting relative was also interviewed about satisfaction with the service provided. Discussions with relatives also lead the Inspector to reassess the management of complaints. The Deputy Manager supported the Inspection process throughout the day. The Registered Manager / Provider arrived at the home for a short period of time but did not contribute to the inspection. Concerns remain about many aspects of the home particularly with regard to the insufficiency of various systems to support health and safety - falls medication management, nutritional need etc. Two letters of serious concern have been sent to the provider following this inspection. What the service does well: Service users and relatives say that the management and staff at the home are approachable and that they listen to any concerns. One relative said that she appreciates the fact that the home always smells fresh and that it is homely and comfortable. Visitors also generally feel welcomed. A relative told the Inspector that she likes the home because it is small, informal and homely. She likes the fact that there are two lounges so Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 6 residents can choose where and with whom they sit. There is a calm and happy atmosphere within the home. A relative said ‘ I can be involved as much as I want to be’. Considerable effort is put into helping residents to celebrate calendar events e.g. Halloween and residents birthdays. Service certificates are up to date to show that electric, gas and fire alarm systems are maintained regularly. What has improved since the last inspection? What they could do better: After some improvement at the last inspection this inspection has seen limited progress and increasing concerns. Health and Safety management remains a concern. Since the last inspection the Environmental Health Department has issued statutory notices to ensure improvement. It was therefore disappointing to find that there were no risk assessments on the premises at all to assess. It has been a previous requirement to ensure that assessments to minimise the risk of accidents from hazardous chemicals are in place. At this inspection they were not. An immediate requirement to ensure improvement was issued. The management of nutrition remains a concern and was subject to immediate requirement along with risk from falls, which has been an on going concern with limited compliance. Records especially at night are not demonstrating that appropriate care is provided to minimise risk and meet need. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 7 Systems in place to manage service users money are wholly inadequate and were subject to a notice requiring immediate improvement. Discussion with relatives highlighted shortcomings in complaints management. Training has not been sufficiently provided for staff in respect of adult protection and the restraint policy also fails to protect service users as staff are not sufficiently guided or informed about this aspect of care practice. Training remains insufficiently evidenced. An immediate requirement issued at the previous inspection to calculate and keep staffing levels under review has not been met and the provider/manager is now in breach of this. The Pharmacy Inspector became aware of continued none compliance with respect to the management of medication and through case tracking identified many areas of concern which will be detailed in a separate report. Eight immediate requirements were issued to bring about improvement in the management of service users medication. There remain an unacceptable number of outstanding requirements with progress towards meeting the national minimum standards too slow. 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 Lane House DS0000025035.V266441.R01.S.doc Version 5.0 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 Lane House DS0000025035.V266441.R01.S.doc Version 5.0 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): EVIDENCE: These Standards were not assessed at this inspection but it was noted that two new residents admitted to the home since the last inspection have not been provided with contracts of residency. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9, 10 Lack of appropriate care planning is failing to sufficiently guide staff and compromising meeting service users needs. Service users are at risk from some aspects of medication management. Service users generally feel they are treated with respect by staff but lack of attention to some detail in the provision of service compromises this. EVIDENCE: There continue to be significant omissions in care plans. Plans do not address all areas of assessed significant need. For example at this inspection it was found that a new resident who had a known and recorded history of falls prior to admission has had two falls at night following admission to the home four weeks ago. A falls assessment with control measures to reduce risk was not undertaken prior to admission and is not currently in place four weeks after admission. The resident is known to disturb regularly during the night to attempt to empty his catheter bag by himself. There is no guidance on his care plan in respect of catheter care, support required at night, frequency of night checks. There is no evidence in records completed by night staff that he has been checked or supported during the night. Oral care is now included on Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 11 care plans but is not always sufficiently detailed e.g. ‘oral care to be carried out night and morning’. This does not guide staff to know what to do and how to do it. A behaviour plan for a resident who has since passed away was not put in place as required. Nutritional risk is being assessed but there are no nutritional care plans in place for any service user including those where a risk has been identified. A previous requirement to amend a care plan to guide staff to meet a residents expressed wish to go out has not been met and outcomes for this service user remain poor. Care plans are however being reviewed monthly and are signed by service users and / or their representatives. The effectiveness of the review however is questionable given the insufficiencies in the care plan itself. A relative spoken to said that she had had the opportunity to see the plan of care which is good practice. The pharmacy Inspector again identified serious concerns in respect of the management and administration of medication, which are detailed in a separate report. One relative spoken to was happy about the level of personal care provided. Another relative had had cause for complaint stating that her husband had not received any personal care for days during the proprietor / manager’s holiday period and was unhappy that staff had not detected that her husband had acquired scabies whilst in the home. The relative also stated that she witnessed a carer shave two male residents in the dining room using the same razor which disregards privacy, dignity and good infection control practice. The complaint has not been satisfactorily managed and therefore the outcome of it is not known. She said however that since her complaint that the level of personal care provided had improved and she is now satisfied with this aspect of the service. A resident spoken to said that staff were generally respectful whilst providing personal care and observed the residents’ privacy and dignity. Whilst residents preferred terms of address are noted a resident said he was not being addressed as he would wish to be. This explains the previous requirement to ensure that there is a written record of a service users life history. This has not been undertaken with sufficient detail and the service user expressed regret about nobody having a sense of who he was and who he had been. He also expressed concern about not having access to a pay phone. He acknowledged that the office phone was available for use but did not find this satisfactory. Currently no service users are sharing a double room. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 15 Contact with family and friends is generally good and is unrestricted. Not all service users are supported to maintain contact with the community, as they would wish. Nutritional need is not being responded to putting the health of some service users at risk. EVIDENCE: A relative said that she is always welcomed at the home and walks in, as she would in her mother’s own home. She said that staff always offers her a cup of tea when she is visiting which she appreciates. She also said her Mother can choose whether she receives visitors in the lounge or in her bedroom and often does both. She appreciates the good communication between the staff and herself whom she said have contacted her at home to clarify family facts in order to provide the resident with reassurance. She said that in the summer she takes her mother out for a walk with staff transferring her mother into the wheelchair to support this. She said there are no restrictions on visiting but that visitors are encouraged to avoid meal times which she felt was understandable. A second relative said that generally staff are welcoming and kind but expressed concerns about an unprofessional response of one staff member in respect of a complaint made. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 13 The relative commented positively on the involvement in the home of the local community. She said she has seen the music / exercise man visiting regularly. She also said that church groups visit at Christmas and relatives are involved in Christmas services held in the home. She appreciated the effort that goes into celebrating calendar events e.g. Halloween and special birthdays where residents and staff dress up and have a party. Local dignitaries and the press have attended to celebrate special birthdays. It was a previous requirement to ensure that a service users expressed wish to go shopping is addressed in her plan of care and facilitated. This has not been met. A resident said that meals are wholesome and sufficient although ‘ordinary’ with drinks available as required. He said that mealtimes are as pleasant as possible. Assessment of documentation however shows that nutritional needs are not being responded to with the outcomes of nutritional assessments disregarded. For example, one resident has since admission in 2001 lost 8kg. She has continued to lose weight throughout 2005 (almost 5kg). The outcome of her nutritional risk assessment shows her score to be at the top end of ‘cause for concern’, which is almost ‘at risk’. Her BMI within the care plan has not been completed so it has not been known whether her current weight is safe and acceptable. Her BMI was calculated during the inspection and with a score of 17 the outcome defined by the BMI is ‘must consult dietician and weigh weekly’. No action has been taken. She has not been referred to the GP or dietician, is not being weighed weekly but has continued to be weighed monthly and there is not a dietary / nutrition care plan in place (for her or other service users) to ensure that individual dietary need is met. Similarly a BMI score of 19 for a second resident, which advises to ‘monitor nutritionally’, has not been addressed. An additional concern is that because of a lack of nutritional risk assessment forms they are not being fully completed and therefore the outcome of the assessment cannot be accounted for effectively. Sufficient tools must be made available. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Service users and their supporters can be confident that complaints and comments will be listened to and acted upon but complainants are not told the outcome of their complaint. EVIDENCE: During the course of the inspection the Inspector became aware of a formal written complaint dated 2.10.05 submitted to the home by a relative about lack of personal care. Whilst it is pleasing that the manager has responded and outcomes are now satisfactory the complaint has not been managed in an open and transparent manner or in accordance with written procedure. Its receipt has not been recorded in the homes complaints book so assessments of the complaint log lead the Inspector to believe that no complaints had been received. It is not clear how effectively or otherwise the complaint has been investigated because whilst performance has improved to the satisfaction of the complainant it is not known whether the elements of the complaint have been upheld. The complainant has not received any written response from the manager / proprietor. There remains ill feeling between the complainant and the staff member involved which would have been avoided by a full conclusion to each aspect of the complaint. A second relative said that the manager and staff are always approachable and respond to comments made where improvement is required. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 Luke warm low pressure water and no gloves in the laundry seriously risks spreading infection. EVIDENCE: The premises are clean with no mal odour. A relative stated that there is never and never has been any mal odour within the home. Required improvements have not been made to the premises to promote good infection control practice as changes are planned if the home is extended. Soap, paper towels and red dissolvable laundry bags are available in the laundry but gloves were not. This along with the availability of luke warm low pressure water in the laundry raises the risk of passing on infection via staff hands. Clean clothes were not being stored in the laundry, which work to minimise some risk. The Inspector was told that the Infection control nurse has been contacted as required for advice but is unable to visit. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 16 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): 29 Knowledge of recruitment processes is improving although the home is not responding to concerns identified, which arise from the checks undertaken to assess the suitability of the applicant. EVIDENCE: A previous immediate requirement to appropriately calculate staffing hours required has not been met. The Inspector was informed that after the given date for compliance the Manager obtained the required tool but has delegated it to a senior staff member to use. The tool requires access to a computer. Neither a computer, fax nor photocopier is available at Park Lane House, which thwarts progress. The manager / proprietor has not ensured that staffing levels have been appropriately reviewed. The home however has 6 resident vacancies and staffing levels have not been reduced from when the home was full. A relative said she did not have any concerns about staffing levels but was not aware of what the levels should be. The manager is not sufficiently aware of staffing levels required, as systems are not in place to calculate and review this. This must be calculated. In the meantime the home remains in breach of this immediate requirement. There has not been any new staff recruited externally. Personnel files were available in respect of two staff members sampled. Some improvement in practice was in evidence with most documents being available including appropriate identification, references, and health checks. Gaps in employment Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 17 history were explained too. There were also updated application forms. POVA checks had not been updated appropriately and concerns arising from the result of one disclosure had not been risk assessed potentially leaving service users at risk. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 18 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): 35, 38 Service users money is not appropriately safeguarded by the systems employed. Systems are not sufficiently robust to minimise risk to protect the health and safety of service users and staff. EVIDENCE: Since the last inspection an application to register a new manager for Park Lane House has been received by the Commission for Social care Inspection and is being processed. The Inspector has been previously informed that the home does not manage service users money. It came to the Inspector’s attention at this inspection that the home does manage service users money and eight individual wallets were being held by the home. Monies provided by relatives are being Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 19 receipted on scraps of paper, which could easily be lost or destroyed. Written records of transactions are not being maintained. A running record of money received and spent is not appropriately logged with no written balance in respect of monies held. Receipts for hairdressing services are available but there are no receipts for monies provided on behalf of one resident to purchase toiletries and hosiery with the exception of stockings receipted in May 2005. It would appear from the lack of receipts that she has not been provided with sufficient hosiery or any toiletries. Twenty Pound was given to the home on this resident’s behalf in October 2005 and there is evidence of one hair appointment (£5.50) since that date. Therefore £14.50 should remain. Instead £12.75 is in her wallet. The discrepancy could not be explained. A relative spoken to and a service user both reported feeling that the home is a safe place to be. All radiators have now been guarded reducing the risk of burns to residents. The Inspector was told that the Environmental Health Department have issued statutory notices to ensure Health and Safety improvement but the notices were not available for the Inspector to see and it was not clear exactly what the notices were in respect of. The manager told the Inspector that a consultant has been appointed to help support improvement and he had removed all the home’s risk assessments to work on them. Such documents must remain on the premises to guide staff. He returned what he had during the inspection but this only amounted in effect to the Fire Risk assessment. No other risk assessments were available. It is a previous requirement to ensure that COSHH assessments are undertaken for hazardous chemicals used and stored by the home. No COSHH assessments were available on the premises putting service users at risk. Less than half of the staff group have undertaken training in first aid, food hygiene and infection control with no certificates available to support this and the Inspector was told that the training matrix was out of date as certificates are awaited in order to update it. All maintenance service records were available and up to date showing that the premises and its equipment are safe. The exception to this is the outcome of the legionella risk assessment which identified works required to minimise risk. The manager said that the plumber had been to undertake some of the work identified but other than a chequebook stub there was no evidence of work done and the manager did not know exactly what work she had paid him for. No action has been taken to meet the Inspector’s ongoing concerns about the proximity of the toilet to the stairs. The Deputy manager said that the Environmental Health officer had shared these concerns yet still no action has been taken to minimise any risk. The risk has not been assessed and no control measure put in place. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 20 Since August 2005 there have been 7 accidents to service users all of which have been falls but action to minimise the risk of falls is insufficient. Moving and handling guidelines are in place but in spite of previous requirement falls assessments are not even where a service user has a known history of falls. Accident records have not been audited as immediately required in September 2004. The Commission for Social care Inspection had not been informed as required of an outbreak of scabies within the home. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 2 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 x X X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 1 X X 1 Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 22 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 OP1 Regulation 4 Requirement The registered provider must ensure that all required information as identified within schedule 1 of the National Minimum Standards for Older People is included in the service users guide. Not assessed at November 2005 First Required prior to August 2003. The registered provider must 31/12/05 ensure that all required information as identified within standard 1.2 is included in the service users guide. At June 05 –, number of places not included, Service user views not included Not assessed at November 2005 First Required prior to August 2003. Service user Guides must be 31/12/05 issued to all residents – current and future. (June 05 not issued to service user admitted April 2005) DS0000025035.V266441.R01.S.doc Version 5.0 Page 23 Timescale for action 31/12/05 2 OP1 5 3 OP1 5 Park Lane House Not assessed at November 2005. Requirement first made March 2004. Terms and conditions of residency must be available for all service users. ( At June and Nov 05 Contract not available for Resident admitted since last inspection 4 OP2 5(3) 31/12/05 5 OP3 14 First Required prior to August 2003. The home must ensure that 30/11/05 service users and their representatives are involved and this is recorded in the pre admission assessment. Not recorded at Nov 05 First Required prior to August 2003. The manager must submit in 31/12/05 writing to the Commission for Social Care Inspection a list of current residents, any known diagnosis and age. The manager must review this list against the registration categories of the home and submit an action plan to the Commission for Social Care Inspection to address any omissions in registration category. Not assessed at November 2005 Requirement first made February 2005. The registered provider must apply for a variation to the certificate of registration for any service users accommodated outside of their current DS0000025035.V266441.R01.S.doc 6 OP4 CSA2000 S.24 10(1) 7 OP4 CSA2000 S.24 10(1) 31/12/05 Park Lane House Version 5.0 Page 24 registration (where their primary need is not due to old age). The home must not accommodate any further residents outside of its current registration. At this (June 2005)inspection need for further variation applications identified Requirement first made and not met since August 2003. Trial visits must be offered to all residents. The offer must be recorded. The detail of the trial visit must also be recorded. Not assessed at November 2005 Requirement first made March 2004 The service users care plan addresses all their needS Care plans must be specific about the regularity of night checks for all individual residents based upon a risk assessed approach and these checks must be evidenced. Requirement first made and not met since June 2005 13, 14, 17 The registered provider and manager must ensure that oral care is incorporated within the daily recording of care delivered. Requirement first made February 2005 and not sufficiently addressed. The following must be present and complete for resident LF and for all residents: Falls risk assessment Requirement first made February 2005. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 25 8 OP5 12(2) 12(3) 15/11/05 9 OP7 15 30/11/05 10 OP8 31/12/05 11 OP8 13 17/11/05 12 OP8 13 Falls assessments must be carried out with safe systems implemented to reduce the risk and number of falls incurred. Was an Immediate Requirement – not evidenced for resident L at Feb 05 or resident JC at November 05 Requirement first made and not met since March 2004 17/11/05 13 OP8 13 To take appropriate documented action to reduce the risk of falls for JC and all other residents who may be at risk of falls. To ensure also that written guidance is given to staff about the level of support required at night for all service users and to ensure that night staff document in detail the support and supervision provided. This must be evidenced to the Commission for Social care Inspection by Thursday 17 November 2005 but action must be taken to minimise risk without delay. Immediate Requirement at November 2005. 17/11/05 14 OP8 17(1)(a) Appropriate action must be taken to meet the nutritional needs of residents at risk with records kept to evidence both full assessment and that nutritional need is being met. Action taken must be confirmed in writing with evidence to the Commission for Social care Inspection by Tuesday 22nd November 2005. 22/11/05 Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 26 Immediate Requirement at November 2005. 15 OP8 13(1)(b) 23(2)(j) The upstairs bathroom must be made safe and accessible for residents to use. The advice of an occupational therapist must be sought and acted upon prior to recommissioning the bathroom. A written criterion for the administration of prescribed ‘as required’ medication in respect of individual residents must be available and based on documented medical advice. The manager must review and expand the medication policy to include all aspects of ordering, receipt, storage, administration, disposal of medications and homely remedies. Risk assessments must be put in place for all residents who holds or self-administer including oral, topical, optical or inhalant preparations oral, topical, optical or inhalant preparations. (Including LF) Requirement first made and not met since February 2005 The manager must investigate, with written outcomes, any gaps in the medication administration records. (Feb 05 – no gaps) The Commission for Social Care Inspection must be informed of any errors/omissions. (No errors to report at June 2005) No gaps at Nov 2005 but prescribers directions not being followed. 30/11/05 16 OP9 13(2) 30/11/05 17 OP9 13(2) 30/11/05 Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 27 18 OP10 16(2)(c) Requirement first made March 2004. The registered person must provide telephone facilities which are suitable for the needs of service users, and make arrangements to enable service users to use such facilities in private. New Requirement at November 2005 31/01/06 19 OP11 12(2) 12(3) 12(4)(a) Similar requirement first made August 2003. The policy on supporting people 31/01/06 who are dying must state that relatives and friends of a service user who is dying are able to stay with him / her for as long as they wish, unless the service user makes it clear that he or she does not want them to. Not assessed at November 2005. Requirement first made March 2004. Residents must be given the opportunity to make known their wishes in the event of terminal care / death. These where made known must be recorded. Part Met at November 2005. Requirement first made and not fully met since September 2004. A Service Users Life Biography, which includes detailed leisure/social interests, is recorded in their records. (Not met for service user case tracked at June 2005.) At November 2005 some evidence but insufficient detail 20 OP11 12(3) 31/01/06 21 OP12 15, 16 31/12/05 Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 28 22 OP12 12 Residents meetings must be fully documented, with copies of the minutes available to the service users. ( At Feb 05- minutes not made available to service users) Not Assessed at November 2005. 30/11/05 23 OP12 12 Requirement first made August 2003. The care plan of EA must be 30/11/05 amended to include expressed wish to go out shopping. This must be risk assessed with the risk assessment adhered to. The care plan must be monitored and kept under review. Requirement first made and not met since June 2005 The registered provider manager 31/12/05 must ensure that the complaints procedure is produced / available in a format which is understandable to all service users. Not assessed at November 2005. Requirement first made February 2005 The manager must ensure that the written complaint received in October 2005 is fully investigated. The complainant must be provided with a written response detailing the outcome of each aspect of the complaint (upheld, not upheld, unresolved etc) with a copy sent to the Commission for Social care Inspection. 24 OP16 22 25 OP16 22, 17(2) 15/12/05 Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 29 26 OP17 12(2) 12(3) The complaint must be fully logged in the complaints book. This requirement was originally made March 2004 and is repeated. The manager must ensure that all residents are consulted about their wishes in respect of voting. Their wishes must be recorded on their care plans and implemented during local and national elections. Action taken to implement wishes must be recorded as evidence. Requirement first made March 2004 and not sufficiently addressed. All staff receive training in awareness of abuse. 3 staff have done, 14 have not No progress by November 2005. To be booked by date set. 31/12/05 27 OP18 13, 18 30/11/05 28 OP18 13(6) 13(7) First Required prior to August 2003. The manager must ensure that 31/01/06 the restraint policy is reviewed in accordance with Department of Health Guidance. Requirement first made and not met since September 2004. The size of all bedrooms and communal rooms must also be included within the statement of purpose and forwarded to the National Care Standards for consideration. Not assessed at November 2005. First Required prior to August 2003. 29 OP20 4,16,23 31/12/05 Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 30 30 OP20 23(2)(f) Communal Space available to each resident must be calculated and included in the Statement of Purpose. This information must be sent to the Commission for Social Care Inspection. Not assessed at November 2005. Requirement first made March 2004. The manager must provide evidence that people who are currently sharing a room have made a positive choice to share with each other and are offered the option of a single room when one becomes available. At Feb and Nov 05 no residents currently sharing. Requirement first made March 2004. The home undertakes an audit of each room recording where all elements of standard 24 are met and identifying the reasons why they are not met. Not assessed at November 2005. 31/12/05 31 OP23 23(2)(f) 15/11/05 32 OP24 16,23 31/12/05 33 OP24 16, 23 First Required prior to August 2003. There are discussions with 31/12/05 residents on facilities provided and decisions made need to be recorded into the service user plan, including key holding, on a risk assessed basis. Not assessed at November 2005. First Required prior to August 2003. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 31 34 OP24 12(3) 12(4)(a) 13(4) Residents must be supplied, subject to risk assessment, keys to their bedrooms. Any restriction imposed must be recorded with reasons given. Not assessed at November 2005. Requirement first made March 2004. The registered provider must ensure that a lockable facility is provided in each of the service users bedrooms. (Provided since last inspection for 3 residents who hold own prescribed creams) Not assessed at November 2005. Requirement first made February 2005 Reference must be made in the Statement of Purpose, Service User Guide and relevant Residents Contracts to the door that connects two double bedrooms that must not be locked 31/12/05 35 OP24 13,14,16 31/03/06 36 OP24 4,5,5(b) 31/12/05 37 OP25 23(1)a Not assessed at November 2005. 30/11/05 A lighting assessment must be carried out of all areas of the home, in particular the dining area and corridors where there is no access to natural light. (Inspectors informed E. Health to do this in April 2005) June 2005 – EHO REPORT AWAITED AS EVIDENCE OF COMPLIANCE At November 2005 - no evidence. Requirement first made August 2003. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 32 38 OP26 13(3) The home has mechanical washer-disinfectors for the effective cleaning of commode pots. To be risk assessed. (Proprietor plans at June 2005 to apply to build extension to meet this requirement) 30/11/05 39 OP26 13,16,17, 23 First Required prior to August 2003. The registered provider manager 30/11/05 must produce procedures for the laundry to prevent contamination from dirty / soiled washing to clean washing. Requirement first made and not met since February 2005 Action must be taken to minimise the hazards identified in the risk assessment undertaken with regard to the lack of ventilation in the laundry. The risk assessment identified the need for an expel air system. All risk assessments must be adhered to. Proposal to address this in proposed extension planned Requirement first made and not met since March 2004. The advice of the Infection Control Nurse and Environmental Health must be sought and acted upon. Requirement first made September 2004. Action must be taken to ensure that the hand washing water supply in the laundry provides water which is at the optimum temperature for safety and infection control. DS0000025035.V266441.R01.S.doc 40 OP26 13(3) 31/03/05 41 OP26 13(3) 31/12/05 42 OP26 13(3) 30/11/05 Park Lane House Version 5.0 Page 33 43 OP26 13(3) New Requirement at November 2005 but requirement made September 2004 to provide hot water in laundry. Disposable gloves must be 15/11/05 available for staff use in the laundry. New Requirement at November 2005. The rota of actual hours worked 30/11/05 must be accurate: The registered provider manager must ensure that it is denoted on the rota the name of any staff member who is covering for another due to sickness, annual leave etc. Not assessed at November 2005. Requirement first made February 2005 Staffing levels must be kept under review including night staffing levels. Requirement first made and not met since March 2004. To calculate care hour weekly requirements using a recognised tool based upon the assessed dependency levels of residents. To provide a copy to the Commission for Social Care Inspection with an action plan where and if required to meet any identified discrepancy between care hours required and those actually provided by the home. Dependency levels and required staffing hours must be kept under regular review. The written outcomes must be provided to the Commission for Social Care Inspection by June DS0000025035.V266441.R01.S.doc 44 OP27 18(1)(a) 45 OP27 18(1)(a) 30/11/05 46 OP27 18 30/11/05 Park Lane House Version 5.0 Page 34 15th 2005 at 5pm. Immediate at June 2005 not met. The home has a minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) achieved by 2005. (On Target at June 2005 - 30 have completed. Plus 20 are working towards NVQ2) First Required prior to August 2003. 48 OP29 Not assessed at November 2005. 17, 18, 19 All recruitment records must be in place prior to the employment of new staff. The manager must be able to demonstrate the authenticity of written references obtained. No new staff at November 2005 Requirement first made February 2005 Appropriate action must be taken in the event of recruitment checks undertaken disclosing concerns about the potential ‘fitness for role’ of an applicant. New Requirement at November 2005. All staff receive a minimum of three days paid training each year. To reassess at end of 12 month period – February 2006 Not assessed at November 2005. Requirement first made February 2005 15/11/05 47 OP28 18 31/12/05 49 OP29 13(4) 19 15/11/05 50 OP30 18 28/02/05 Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 35 51 OP30 18 Every member of staff has a Training and Development plan. Progress made. Training plans in place for some staff – templates established and on individual staff members files ready for completion Not assessed at November 2005. 31/12/05 52 OP30 18 First Required prior to August 2003. The home’s induction and 31/12/05 foundation training meets National Training Organisation standards. Not assessed at November 2005. First Required prior to August 2003. 31/12/05 A team-training matrix that identifies all mandatory and vocational training for all staff. This must indicate dates that training has been undertaken, when refreshers are due and dates for training courses that have not been undertaken. · Training certificates must be reorganised and must correlate to the dates on the training matrix. · A minimum of three paid training days per year for all staff must be provided. · Appropriate Induction training must be completed within 6 weeks of appointment to post Appropriate Foundation training must be completed within 6 months of appointment to post 53 OP30 18 Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 36 Requiremenmts not assessed at November 2005 although it is noted that the matrix had not been kept up to date. Requirement first made February 2005 All staff must be provided with up to date training in the care of diabetics. To be booked by date set Requirement first made and not met since August 2003. Staff and managers must be provided with tissue viability training. To be booked by the date set Requirement first made and not met since September 2004. All staff must receive training in first aid, food hygiene, Infection control,adult protection. Training must be booked for all staff by the date given New Requirement at November 2005. Senior staff and managers must receive training in supervision skills including regard for the role and function of supervision. Training must be booked by 31/12/05 New Requirement at November 2005. The manager holds an NVQ 4 (or equivalent). (Manager has not enrolled on a course At June 2005 Deputy manager nominated for this course) Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 37 54 OP30 18 30/11/05 55 OP30 18(1)(c)(i ) 30/11/05 56 OP30 18 31/12/05 57 OP30 18 31/12/05 58 OP31 18 31/12/06 At November 2005 Deputy Manager to begin December 2005. First Required prior to August 2003. The registered provider manager 31/12/05 must ensure that all staff read, sign and date all written policies and procedures operational within the home. Not assessed at November 2005. Requirement first made February 2005 The home must have an annual development plan. The results of service user surveys must be published and made available to residents, relatives, third parties and the Commission for Social Care Inspection. Not assessed at November 2005. Requirement first made March 2004. The manager must submit to the Commission for Social Care Inspection an Annual Development Plan for the home by the date set. 59 OP33 17, 18 60 OP33 24 01/04/06 61 OP33 24 31/12/05 62 OP35 17(2) Sch 4 (9) Requirement first made and not met since September 2004 To improve records in respect of 22/11/05 the management of service users money to appropriately account for money received, held and spent by the home on service users behalf and to confirm action taken in writing to the Commission for Social Care Inspection by Tuesday 22nd DS0000025035.V266441.R01.S.doc Version 5.0 Page 38 Park Lane House November 2005. Immediate requirement at November 2005. In March 2004 the provider was required to clarify in writing to CSCI its position re holding service users money. 63 OP35 17(2) Sch 4(9) 37 The manager must audit monies held on behalf of all service users. The manager must investigate any discrepancy including that found for service user JW and explain the discrepancy and any corrective action taken in writing to the Commission for Social care Inspection. 31/12/05 64 OP36 18(2), 21 New Requirement at November 2005. Care staff receive formal 31/05/06 supervision at least 6 times a year, with an appropriate level of clinical and supportive supervision for all other staff. First supervision for all staff must be achieved by 31.5.04 (Evidence not available to assess at Sept 04) Not met at Feb 05 One supervision undertaken for all staff at June 05 At November 2005 four observed practices documented June - Nov 2005. First Required prior to August 2003. Where staff have identified 30/11/05 support needs this must be risk assessed and control measures agreed as part of the supervision process. The manager must ensure that DS0000025035.V266441.R01.S.doc Version 5.0 Page 39 65 OP36 18 Park Lane House all staff including senior staff are aware that they are not to undertake invasive practices and to ensure they understand the definition of invasive practice. Action taken to meet this must be evidenced. Not assessed at November 2005. The registered provider manager must ensure that all staff receive one to one formal supervision as per standard 36. At November 2005 observed practices documented rather than formal supervision. Requirement first made February 2005 All incidents as defined under Regulation 37 must be notified in writing to the Commission for Social Care Inspection without delay. (Incident between residents recorded in complaints book 3.2.05 not notified. Death 11.5.05 not notified until 6.6.05 day prior to announced inspection) At November 2005 inspection scabies outbreak not notified but other notifications received indicating some progress. Requirement first set as an immediate requirement September 2004 COSHH assessments for all chemicals including household cleaning agents used within the home must be undertaken and made available to staff and kept in close proximity to the substance. DS0000025035.V266441.R01.S.doc 66 OP37 17(3)(a) 37 15/11/05 67 OP38 13, 23 22/11/05 Park Lane House Version 5.0 Page 40 Not met. See new immediate requirement issued November 2005. Requirement first made and not met since February 2005 To undertake COSHH assessments for all hazardous chemicals stored and used by the home and to provide copies to the Commission for Social care Inspection by Tuesday 22 November 2005. Immediate requirement at November 2005. The registered provider manager must ensure that the fire risk assessment pertaining to the premises, equipment and furnishings is revised and complies with all current legislation. At November 2005 reviewed but sufficiency of risk assessment must be discussed with Fire Service. Requirement first made February 2005 All requirements made by Environmental Health Officer following recent visits must be met. Environmental Health Officers return visit – 20.4.05 A copy of the report when received must be forwarded to the Commission for Social Care Inspection. Requirement first made February 2005 68 OP38 13 22/11/05 69 OP38 13,17,23 30/11/05 70 OP38 13 31/12/05 Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 41 71 OP38 13, 18 All staff receive annual moving and lifting training. (Certificated evidence at June 2005 that some staff have undertaken since last inspection Not assessed at November 2005. 31/12/05 72 OP38 First Required prior to August 2003. 13(4),23,( The manager must risk assess 30/11/05 2a j) the toilet on the first floor due to its proximity to the top of the stairs. The risk assessment must be kept under review in light of advice given. Advice must be sought from the West Midland Fire Service and Environmental Service Department about the safety of the position of this toilet at the top of the stairs. Advice must be requested in writing. A general risk assessment with respect to the security of the building must be undertaken. This must include the side entrance. Requirement first made and not met since March 2004. Action must be taken if the regular taking of residents weight shows rapid weight loss or weight gain – no issues identified June 2005. At November 2005 see new Immediate requirement issued. All accidents for the previous 12 month period must be analysed, the risks assessed and recorded and safe written systems must be implemented to reduce the possibility of any risks identified. 73 OP38 13(4)(1b) 37(1)(e) 30/11/05 Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 42 Referral to an Occupational therapist will be required but safe systems must in the meantime be implemented. This must be completed by Friday 1st October 2004 and posted to the Commission for Social Care Inspection on this date Immediate Requirements at September 2004. Contraventions of fire safety indicated in the Fire Officers report dated October 2004 must be addressed. Action taken in respect of Fire Doors must be approved by the Fire Service Requirement first made September 2004. 75 OP38 13(4) Not assessed at November 2005. Action taken to minimise the risk of legionella identified in the commissioned water report must be taken and evidenced to the Commission for Social care Inspection. 31/12/05 74 OP38 24(3)c(i) 23(4)(d) 30/11/05 76 OP38 37(1)(e) 23(5) New Requirement at November 2005. The registered person must 31/12/05 provide the Commission for Social care Inspection with copies of statutory notices issued by the Environmental Health Department. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 43 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 4 5 Refer to Standard OP2 OP3 OP12 OP28 Good Practice Recommendations Trial periods must be for 12 weeks. This must be stipulated in the terms and conditions of residency contract and amended from 28 days. The Manager was advised to consider that a senior member of the home’s staff perform the pre admission assessment prior to admission to the home The home appoint an Activity Organiser or identify a member of staff who has a responsibility to plan, organise and evaluate activities within the home. The home has a minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) achieved by 2005. Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 44 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Park Lane House DS0000025035.V266441.R01.S.doc Version 5.0 Page 45 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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