Inspection on 04/01/07 for Park Lane House

This inspection was carried out on 4th January 2007.

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 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 01/07/08

Park Lane House 06/06/07

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Park Lane House 163 Tipton Road Sedgley Dudley West Midlands DY3 1AA Lead Inspector Mr Jon Potts Unannounced Inspection 10:05a 4 & 5th January 2007 th 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.V322369.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.V322369.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 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 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.V322369.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. 05/05/2006 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 care 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 would have difficult accommodating residents with high physical dependencies due to the facilities the premises offers, with steps to some bedrooms and toilets that are too small for wheelchairs. The Provider has installed ramps, handrails and the home does have a passenger lift. 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. 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 are between £318.00 and £336.00 per week, this correct as of the 4/1/07. This fee includes all basic care and food requirements. Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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 as to the homes compliance with the same. The inspector case tracked the care of three residents and evidence was drawn from case files, discussion with and observation of staff, sampling of procedures, inspection of areas of the home, and discussion with some residents. Selected staff files, training records and management records were also sampled. Comments from residents were also supplied to the CSCI preinspection. The residents, deputy manager and staff are to be thanked for their assistance with the inspection process. What the service does well: What has improved since the last inspection? A number of requirements from the previous inspection have been addressed including improving care staffing levels, training of staff in adult protection, part improvement in some of the paperwork (for example better falls risk assessments, some signatures on care plans) and better presentation of liquidised foods. There has been provision of training in abuse and a number of mandatory areas such as first aid, moving and handling and food hygiene. Discussion with the deputy did evidence that the procedure for admission of residents had improved or was more structured and there was evidence of reviews with social workers and families for social service funded residents. There was evidence of some efforts to improve the records within residents case files although some issues still remain. Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 6 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.V322369.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.V322369.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 standards: 1,2,3,4,5 Standard 6 is not applicable to this home. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have opportunity to access information they need to choose a home, which meets their needs, but not always in written form. They have their needs assessed and a contract which gives them basic details of the service they will receive. EVIDENCE: The admission of new residents is based on a degree of pre admission work that would involve discussion with the prospective service user and their representatives. Discussion with the Deputy manager evidenced that she 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. A trial visit to the home would be offered, this in writing, so that the service user can sample the service, meeting other residents and trying a meal etc. Records of this trial visit are not however Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 9 documented. The Deputy has carried out assessments to meet prospective service users in some cases but stated was not on duty when one was admitted – so not there to greet the resident as the only one to have previously meet them. There was no evidence of the service users having been given a copy of the service users guide, and residents spoken to do not recall whether they were given one. Contracts were in place for all case files 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. Staff do not always have the necessary skills and ability to care for residents as it was noted some recent admissions are residents with dementia and staff do not have training in the area. Whilst those residents admitted would not seem to have advanced dementia, with the home possibly meeting their needs at present, there is concern that if the dementia was to progress the home’s staff may not have the necessary knowledge and skill base to respond to these changes in need. The Deputy was aware of the need to use the assessment information to make a decision as to whether the home was able to meet the residents needs (Social worker reviews seen confirmed that home was meeting needs following admission in respect of those cases the inspector examined) but it was noted that the home did not confirm its ability to meet this need until well after admission, not prior to as required by law. The home has developed a statement of purpose, one copy found in the foyer of the home. There was however only one copy of this document and this still required some minor revision to meet standards i.e. reference to providing a service to mentally ill residents was inaccurate. There were two copies of the homes service user guide found in the office, this with inserts showing some review since the last inspection. The Deputy did however state that she did not have spare copies to take out on pre-admission assessments and although it was stated that residents have copies in their bedrooms none were seen in those rooms the inspector went in. The documents were in a standard written format with no use of photos or pictures, which would make the document more accessible for some service users. The Certificate of registration that was on display in the home was not the current one, and did not have the current manager’s name within it. The home must have the current certificate of registration on display so that people have access to the correct information as to the homes registration. There was however clear evidence that the recently admitted and existing social service funded residents have received care reviews recently. This has not however extended to privately funded residents. Park Lane House DS0000025035.V322369.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 standards: 7,8,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care, which a resident receives, is in most cases based on their individual needs, but there are times when some needs are not followed through. Care plans need expansion to cover the full range of needs an individual may have. The principals of respect dignity and privacy are put into practice although compromised by the environment at times. No judgement has been made in respect of the handling and administration of medication at this time and any future outcomes following the CSCI pharmacy inspectors visit may influence the overall judgement for this group of standards. EVIDENCE: Residents have a care plan with some evidence of their involvement within this. The plans are reviewed on a monthly basis. The plan includes the basic information in respect of some aspects of care, sufficient to enable the development of the plan, although the focus of the plans themselves are Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 11 mostly in respect of physical and health care needs and need development to include social care needs in greater detail. Of some concern was the fact that information in some of the plans is inaccurate when discussed with staff and residents. There was in some instances evidence of updating on the plans to reflect changing needs on the care plans, with evidence of multidisciplinary reviews carried out for social service funded residents. Residents have access to the majority of health care services, this meeting the majority of their assessed needs although discussion with one resident indicated that they had some difficultly eating, this observed by the homes deputy manager. Whilst foods were presented so as to assist eating the resident did indicate that they would like new dentures, this an option not explored by the home. It was also unclear as to whether one resident’s hearing difficulties had been explored in sufficient depth. There was clear evidence of the home maintaining health care treatment and intervention in respect of tissue viability and nutrition, this including weight monitoring, but not always within the timescales documented in the case file. Appropriate action in involving health professionals based on tissue viability and nutritional concerns was seen to be taken however (i.e. involvement of the dietician, district nurse). Staff confirmed that where there were concerns in respect of skin breakdown there was a two hourly turning regime in place to supplement the use of pressure relieving aids, this not documented on plans however. There was evidence that incontinence assessments have been carried out by district nurses but the regime for the management of incontinence pad usage was not available in documented form, although the deputy manager verbally recounted this. Due to some concerns in respect of medication administration the inspector has requested the CSCI pharmacy inspector to assess the outcomes in respect of this area. 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. The home allows residents access to privacy and when wished they are able to enjoy this by spending time in their own rooms. In shared rooms screening is available. There was concern as to providing privacy when residents were assisted to use the toilets by the office due to their size. Staff saw this as an issue. Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standards: 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. Residents have some scope to make lifestyle choices in respect of their daily routine and contact with relatives is encouraged. Social, cultural and recreational activities are limited and not always available as planned, and do not always meet all the residents expectations. Residents receive a healthy, varied diet according to their assessed requirements and choice. 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 some consultation with residents around what these wishes were. There was evidence of staff providing some flexibility in the way they provided care to meet with residents wishes, this in accordance with some of the homes policies and procedures. Whilst there was some documentation of residents preferences in respect of activities documented in case files, and an activities programme displayed in the homes dining room there was little evidence of activities been made available with two of the programmed activities seen not to take place at the Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 13 advertised time. Individual records in respect of those residents whose care was tracked showed that there was little variety in what activities were offered, with the majority of those that took place very sedentary and questionable in terms of stimulation (such as resting, TV, bed rest). There was occasional reference to such as crafts, sitting in the garden, music and movement. Whilst comments from the residents spoken to at the home indicated satisfaction with the levels of activity out of five questionnaires returned to CSCI only one said activities were always provided. The home has an in house church service once a month. One resident spoken did indicate that they would like the opportunity to go to church. There was no evidence of the home arranging community-based events. The home has open visiting arrangements and residents are able to entertain their friends and visitors in their rooms if they wish. There are also a number of communal areas where the residents can sit with visitors so as to negate any intrusion on other residents. Residents are able to manage their own money if able, but in the cases seen assistance is provided by relatives with money left at the home as needed, within safekeeping, for small purchases (such as hairdressing). Information in respect of advocacy services was available at the home but there are currently no advocates involved with residents, although relatives and residents are encouraged to retain involvement. Residents are 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. The food in the home was seen to be of good quality, well presented and meeting the dietary needs of the residents. The cook and staff consult with residents as to their choices and preferences in respect of meals on a daily basis and are able to offer choices. Staff were seen to assist those residents unable to feed themselves appropriately and foods are presented as needed to assist with easy digestion. Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standards: 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents have access to a complaints procedure that meets the basic standards expected but practice in handling complaints needs to be more robust. Whilst residents feel safe at the home the service must be more proactive in the way it responds to issues that may put residents at risk. EVIDENCE: The service has a complaints procedure that generally meets the national minimum standards and regulations. The complaints procedure was seen to be available within the home although would be better in large print. There is information as to how to complain in the terms and conditions of residency. Five resident Questionnaires returned to the CSCI pre inspection all indicated that respondents were aware of the homes complaints procedure and that staff listened to, and acted upon what was said. One resident spoken to was quite clear that they felt able to raise any concerns and was confident that they would be dealt with. The home has access to the local authorities vulnerable adult procedures although there was a concern that an issue that put a resident (and staff) at potential risk due to moving and handling practices was not addressed until raised by a visiting professional. Neither had this complaint/concern been documented within the homes complaints book. In addition concerns raised Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 15 with the Registered Manager at the time of the last inspection had not led to a conclusion without any information relayed back to CSCI. There was concern that the maintenance man who did repairs at the home, and had at the time of the last inspection been seen to have unsupervised access to the home, was not subject to enhanced disclosure. On a more positive note staff training in adult protection has continued with this having some limited content relating to the use of restraint (as evidenced through staff discussion). The provision of additional training in this aspect of care provision would however be beneficial, perhaps as a wider input into dementia care training. Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standards: 19,21,22,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a comfortable and clean environment, although the lack of a proactive maintenance and refurbishment programme raises concerns. EVIDENCE: The service provides a homely environment although there is no rolling programme in respect of improvements to the decor, fixtures or fittings. This is a concern as some of the furniture whilst adequate at present will in time need replacement and there is no forward planning identified to carry out this refurbishment when needed. The home has mostly single rooms with a few doubles, most of the latter single occupancy or unoccupied. Residents are able to personalise their rooms and can choose where to sit in communal areas. Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 17 Residents expressed satisfaction with the accommodation, the home was clean and there was sufficient hot water available. There are sufficient bathrooms but the toilets by the office on the ground floor, these the closest to the main living areas, are quite small and this creates difficult for residents and staff when residents need assistance, as there are times where it is difficult to close the door and preserve privacy. Residents asked did not hold keys to bedroom doors, although were unconcerned as to this matter. There was however no documentation in case files to show that this was explored with the resident and that it was there choice not to hold keys, or a risk assessment to indicate why it would be too much of a risk for them to hold keys. Again residents asked were content with the furniture provided by the home in their bedrooms, but there was no documentation to show that there had been discussion as to what items the residents may or may not require, when considering what national minimum standards prescribe as the minimum. There have been no recent outbreaks of infections and the home was seen to have appropriate procedures in place for the control of the same. Liquid soap and paper towels were seen to be available for staff uses as was protective wear such as gloves and aprons, these seen to be used by staff whilst carrying out personal care. The only issue of concern in this area was in respect of the homes legionella risk assessment, an issue that has been raised by Environmental Health. There are some other areas that present a potential risk to residents including some hot water pipes not covered, a fire door that does not shut fully into its rebate on the main landing, and damaged carpet by bedroom five (this identified as needing attention but not addressed). There was also damage to the flooring in the kitchen and a hot tap in room 11 was loose. Overall the home was well lit, although there was an issue with one resident persistently turning off lights in the main hallway and lounges leaving these quite dim. This was not risk assessed. Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standards: 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There was sufficient staff available to fulfil the aims of the home and meet the changing needs of residents at the time of this inspection. Training in most mandatory areas was seen to be adequately managed but there was a lack of insight into developing training targets based on the changing needs of the residents. Poor Recruitment practice was seen to put residents at potential risk. EVIDENCE: Residents are generally satisfied that the care they receive meets their needs, and it was noted that there has been an improvement in the staffing levels since the time of the last inspection. Residents felt that the staff did a good job and delivered care in a friendly and caring way. Staffing rotas try to take into account the times of high and low activity. Whilst there has been further input into training, and delivery of a training programme that meets most statutory requirements, there are still some areas based on the needs of residents where attention is still required. The service is also able to recognise in most cases (but not all) where additional basic mandatory training is needed, and attempts to plan over time to provide this training. There is training need that would benefit the staff and residents due Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 19 to the residents changing needs that is not as readily identified and provided, this including such as dementia training. It was of note though that the majority of the staff have received NVQ level 2 training in care. The service has a poor recruitment procedure with shortfalls in recording and process being evident and including the lack of POVA 1st checks in one instance. Where these had been received there was not any evidence of a risk assessment in place to acknowledge the additional risk present prior to receipt of the enhanced disclosure. In addition to the above there was one member of staff employed without two references and induction was not to current skills for care standards (this stated to be the case by the deputy). Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of proactive management, administration and a robust, effective quality assurance systems means shortcomings, some that present risk to residents, are not addressed. EVIDENCE: The Registered Manager of the home at the time of the inspection was on a period of protracted leave and the deputy, whilst NVQ level 4 qualified and a having had a long period as a deputy/senior at the home, has only basic management skills and minimal experience of running the home as a manager. There was concern that the deputy was not sufficiently prepared to run the Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 21 home in regard to all management tasks in the absence of the substantive manager, such as strategic planning and review. Policies and procedures are reviewed although some practices outlined in these were not followed in respect of management tasks, an example been the home’s equal opportunities policy, this identifying that there will be six monthly equalities action plans at Quarterly management review meetings. There was no evidence available on these. Resident’s interests are not always fully safeguarded as evidenced by poor record keeping. This has lead in some circumstances to putting service users at risk, for example care plans that give inaccurate directions, inventories of residents property that are not updated. Quality assurance monitoring is not regarded or is implemented in a very limited fashion as a core management tool. The CSCI has not received any copies the reports from the providers monthly unannounced visits as is required by legislation. The home is drifting and lacks some purpose and direction, although care staff spoken to, and the deputy did show a marked interest in the performance of the home. There was evidence that the staff are gradually reading and signing to say they have read the homes policies and procedures, which are available in the homes office, although staff meeting minutes seen made limited reference to discussion of these or the homes philosophy and direction. 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 such as general health and safety training. A recent visit from Environmental services did however highlight some areas of concern, some issues addressed, some not. The Deputy was advised to contact the Environmental Health officer to discuss these issues, or pass this information on to the provider. It is of concern that whilst risks may be identified (i.e. a tripping hazard due to damaged carpet by room 5) and brought to the provider’s attention, these are not addressed according to the risk they present to residents. It was also noted that one resident had two accidents in the time they had been at the home, and only one was documented within the homes accident book. Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X 2 2 X X 2 2 STAFFING Standard No Score 27 3 28 4 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 X 1 2 Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Any requirements from the last inspection in respect of standard 9 have not been repeated (with one exception) due to the forthcoming CSCI pharmacist’s inspection. It is possible that they maybe repeated in the subsequent report. YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation Care Standards Act 4(1)c Schedule 1 Requirement The home must display its current certificate of registration in a prominent place within the home. The registered provider must ensure that all information as detailed in Schedule 1 of the Care Home Regulations 2001 must be available in the homes Statement of Purpose. The following areas still require inclusion/attention. - It needs to be clearer that the home offers a service primarily to older people in accordance with its registration. - The criterion for admission needs to be clearer with reference to the need to admit residents within its categories of registration. - The size of rooms. Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 24 Timescale for action 28/02/07 2. OP1 31/03/07 3. OP3 14(1)d This is a repeated requirement that was to have be addressed by the 31/7/06 The provider/manager must confirm in writing to all prospective residents the home’s ability to meet assessed needs prior to admission. This is a repeated requirement that was to have be addressed by the 18/5/06 Staff are to be provided with appropriate training in dementia care. To ensure that care plans are accurate and also include the following: - Signatures of the resident or their nominated representative on the most up to date copies of all plans; and - All social/emotional aspects related to a residents care To ensure that moving and handling assessments are carried out by appropriately qualified personnel in respect of residents F.B. and G.R. Any recommendations made following these assessments must be followed. To ensure that residents receive dental treatment as and when needed. To ensure that clear directions as to the outcomes of an continence assessments are clearly detailed in care plans/case files To ensure that tissue viability assessments carry details as to the turning regime for residents where this is appropriate. Where there are concerns as to the effectiveness of a resident’s hearing aid then steps must be DS0000025035.V322369.R01.S.doc 28/02/07 4. 5. OP4 OP7 18(1)c 15(1) & 2(d) 30/06/07 31/03/07 6. OP8 13(5) 28/02/07 7. 8. OP8 OP8 13(1)b 13 & 14 28/02/07 31/03/07 9. OP8 13 28/02/07 10. OP8 13(1)b 28/02/07 Park Lane House Version 5.2 Page 25 11. OP9 13(2) taken to follow this up. The medicated creams/ointments not designated for selfadministration, which are being stored in the residents rooms must be removed and stored within the home’s locked facilities. The home must ensure that all medication, which has not been designated for selfadministration must be kept secure so that unauthorised persons do not have access to them. Creams found to be in lockable drawers with keys left in the locks. 28/02/07 12. OP12 16(2)n 13. OP16 22(4) 14. OP16 22 This is a repeated requirement first made 08/07/05. When activities that are planned, 31/03/07 and are in accordance with those agreed with residents, they must be provided as detailed in the homes activity programme. Care plans should detail how the home intends to meet resident’s individual needs in respect of social and religious needs. All complaints received by the 28/02/07 home must be detailed in a record that summarises the concerns and the actions taken to address them. 31/05/07 The manager is to respond in writing in respect of the concerns raised at the time of the inspection in May 2006. This is a repeated requirement that was to have been addressed by the 18/6/06. The date to meet this requirement is made with regard to the registered Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 26 15. OP18 13(6)(7)1 8 manager’s current leave. To ensure that staff have a better awareness of restraint i.e. what it is and how ensure strategies for its avoidance (documented in behaviour plans) are employed wherever possible. Where restraint is to be used it must be documented and agreed within a multidisciplinary forum. This is a repeated requirement that was to have been fully met by the 31.7.06. All persons working at the home that are not part of the regular staff team, but may have unrestricted access to service users must be subject to an enhanced disclosure. This is a repeated requirement that was subject of an immediate requirement left at the home on the 5/1/07. The homes refurbishment programme must be available and be reviewed to include on going progress towards its achievement. This is a repeated requirement first that was to have been addressed by the 31/7/06 The following works must also be attended to; 1. The carpet by room 5 is to be made safe. 2. The tap in room 11 is to be secured. 3. The kitchen flooring is to be repaired/replaced. 4. The fire door at the top of the main landing must 31/05/07 16. OP18 13(4)c 15/02/07 17. OP19 23 28/02/07 Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 27 shut fully into its rebates. 18. OP25 13(4) A risk assessment must be carried out in respect of the resident that switches off lights so as to ensure any risks this presents are negated. No staff are to be employed at the home prior to receipt of a POVA 1st check. 28/02/07 19. OP29 19 05/01/07 20. OP29 19 This requirement that was subject of an immediate requirement left at the home on the 5/1/07. No staff are to be employed 15/02/07 without a disclosure without the registered manager/ provider completing a risk assessment and discussing the same with the CSCI. This risk assessment is to identify how the risk to service users will be reduced / removed from the employment of staff for which the home does not have a full enhanced disclosure. This is a repeated requirement that was to have been addressed by the 18/5/06 Two references must be obtained 15/02/07 for all new staff prior to employment. 31/05/07 Staff and managers must be provided with tissue viability training. Requirement first made September 2004 This is a repeated requirement that was to have been addressed by the 31/5/06 Health and safety training is to be provided to all staff. DS0000025035.V322369.R01.S.doc 21. 22. OP29 OP30 19 18 23. OP30 18(1)c(i) 31/05/07 Park Lane House Version 5.2 Page 28 24. OP30 18(1)c(i) 25. OP31 9 18(1)c(i) The provider must ensure that all staff receive sufficient induction in accordance with national standards. The manager holds an NVQ 4 (or equivalent). (Manager has not enrolled on a course First Required prior to August 2003. 31/03/07 31/08/07 26. OP33 17, 18 The home is unable to address at present as the registered manager is on extended leave. The date prescribed makes allowance for this. The registered provider manager 31/03/07 must ensure that all staff read, sign and date all written policies and procedures operational within the home. Requirement first made February 2005 27. OP33 26 Part Met at May 06 and Jan 07 The provider must arrange for unannounced monthly regulation 26 visits to be made to the home to interview service users, relatives and staff in private, to inspect the premises, records of events and complaints to form an opinion on the standard of care provided. A report detailing the outcomes must be prepared following each such visit and a copy must be provided to CSCI and the Manager. This requirement was first made in February 2006 and was to have been met by the 21/6/06. An effective quality assurance system must be introduced at DS0000025035.V322369.R01.S.doc 28/02/07 28. OP33 24 31/05/07 Park Lane House Version 5.2 Page 29 29. 30. OP35 OP38 13 17(2) 23(5) 31. OP38 17(2) Schedule 4 the home. Inventories of resident’s property 31/03/07 must be kept up to date. The provider must liaise with the 28/02/07 appropriate Environmental Health officer in respect of requirements from their last report that remain outstanding. All accidents must be recorded in 28/02/07 the accident report book. 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. 5. Refer to Standard OP3 OP15 OP16 OP18 OP24 Good Practice Recommendations The home should ensure that the service users and their representative’s involvement in pre admission assessments is documented. To develop menus in pictorial formats. 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 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. If items are as listed in this standard are not provided why they are not provided i.e. keys to bedroom doors and so on. This issues should be discussed with the resident/representative with documentation of non provision in risk assessments where appropriate. Park Lane House DS0000025035.V322369.R01.S.doc Version 5.2 Page 30 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: 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.V322369.R01.S.doc Version 5.2 Page 31 - 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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