Inspection on 06/06/07 for Park Lane House

This inspection was carried out on 6th June 2007.

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

The inspector 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 04/01/07

Park Lane House 09/05/06

Park Lane House 15/11/05

Park Lane House 07/06/05

Park Lane House 01/02/05

Park Lane House 28/09/04

Park Lane House 31/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 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 Key Unannounced Inspection 6th June 2007 9:45 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.V342422.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.V342422.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.V342422.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. 6th February 2007 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 disabled toilet facilities will however be improved within the current building works at the home. The Provider has installed ramps, handrails and the home does have a passenger lift. The home has car-parking facilities on the side of the home, these limited at present due to on going work to build an extension to the home. The home is situated on the main Tipton Road between Sedgley and Tipton, on a bus route and easily accessible by car. The home is owned and operated by two individuals who employ a manager to run the home on a day-to-day basis. The manager supervises a deputy, seniors and carers as well as ancillary staff (including cook ands housekeeper). The charges for residency are £343.00 per week, this correct as of the 14/6/07. This fee includes all basic care and food requirements. Park Lane House DS0000025035.V342422.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 the homes compliance with the same. The inspector case tracked the care of four residents and evidence was drawn from case files, discussion with/observation of staff, sampling of procedures and inspection of most areas of the home. There was also discussion with some residents and their relatives. Selected staff files, training records and management records were also sampled. The residents, manager and staff are to be thanked for their ready assistance with the inspection process. What the service does well: What has improved since the last inspection? Numerous requirements from the previous inspection have been addressed, or there was clear evidence to show that work was well in progress in terms of meeting these. Whilst there are still issues in respect of the quality of the accommodation, work on an extension has commenced and the inspector was told that a complete refurbishment of the home would follow. This was seen by the residents spoken to as a positive as they felt the home would benefit from updating. In addition the manager has put a quality assurance system in place and is developing this with a clear correlation between the audits carried out and national minimum standards, and therefore outcomes for residents. Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 6 Staff training has continued, and whilst there are still areas where training is needed there was clear documented evidence to show this had been booked. Initial training in dementia care has already taken place. 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.V342422.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.V342422.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 5 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 that can meet their needs, this with the option of a pre admission visit made available to assist them. Their needs are assessed and a contract, which gives them basic details of the service they will receive, is made available. 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 manager evidenced that she or other managerial staff would, following receipt of any referrals visit the service user and carry out an assessment to supplement any assessment provided by the social services department, which were seen to be available for those residents recently admitted. It was stated that relatives/prospective residents are free to Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 9 visit the home prior to any referral, and this was seen to be confirmed by copies of letters to them, as well as through verbal confirmation by residents/relative to the inspector. The trial visit to the home would be for the purpose of allowing the service user to sample the service, meeting other residents and trying a meal etc. Records of these trial visits were now seen to be subject to some recording, with standardised forms devised for this purpose. The manager stated that as the service users guide has only been reviewed recently, completed copies of the same have not been available to the last few residents admitted to the home, but time has been taken to give verbal explanation as to what could be expected at Park lane. Discussion with the residents/relatives recently admitted did not indicate any difficulties with their admission to the home. It was noted that on the second day of the inspection, whilst touring the home, that there were copies of the services users guide available in residents bedrooms, underlining the statement made previously by the manager that these would be circulated. Contracts were in place for all residents whose case files were examined, these signed by representatives. These set out basic information on what residents can expect to receive for the fee they pay and also sets out terms and conditions of residency. The manager was however advised to clarify the point in respect of the home accepting no responsibility for residents when going out, this as it did not specify whether they maybe going out with relatives (where the home would not be able to take responsibility) or staff (where they would). The home has reviewed and improved its statement of purpose and service users guide, which was found to be acceptable. There was however reference to the manager having nurse training, this presumably referring to the provider not the manager. In addition a summary of the residents views (which was seen to be available as part of the homes quality assistance system) should be included with the service users guide. 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. Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care, which a resident receives, is based on their individual needs. Care plans reflect resident choices and needs underlining their involvement in putting these together. The principals of respect dignity and privacy are put into practice although compromised by the environment at times. EVIDENCE: The service involves individuals in the planning of care that affects their lifestyle and quality of life this evidenced through discussion with them. Residents or their representatives had also signed the plans. Staff, and the manager, in discussion understood the importance of residents being supported to take control of their own lives, with choices documented. Plans were seen to be are reviewed on a monthly basis, with updates based on any changes to need. The plans include information as to the full range of the individuals care needs whether they are physical, social or emotional with Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 11 health needs clearly detailed, this building on the homes assessment and dependency profiles. Tracking of the information in the plans with comparison of this with information provided by residents, relatives and staff (as well as documented in other records) showed that the plans were accurate and the plan of care detailed was actually provided by the service. In most instances there was evidence of multidisciplinary reviews carried out for publicly funded residents. Residents have access to the all community health care services as needed and as identified within care plans. Issues in respect of residents not accessing dental services at the time of the last inspection have now been fully addressed. The manager is arranging further access to training in health care matters for staff with training booked, this including tissue viability. The aims and objectives of the home reinforce the importance of treating individuals with respect and dignity. There was clear evidence of the home maintaining health care treatment and intervention in respect of tissue viability and nutrition, this including weight monitoring. Appropriate action in involving health professionals based on tissue viability and nutritional concerns was seen to be taken. There was evidence that incontinence assessments have been carried out by district nurses with the regime for the management of incontinence pad usage documented within care plans. The manager has revised the homes medication policy and procedures and this is now much improved. Medication records are fully completed, contain required entries, and are signed by appropriate staff. There was one discrepancy noted which was resolved prior to the completion of the inspection. Weekly management checks are recorded to monitor compliance. People who use services are given the support they need to manage their medication where they wish to and the home has supported diabetics to carry on with self administration of their insulin within a risk assessment framework, this with the support of local district nursing services. If individuals prefer or where they lack capacity, care staff can manage medication. Thought has been given to providing safe facilities for keeping medication. The home practices in respect of the receipt, administration, safekeeping, and disposal of Controlled Drugs has improved. Staff who administer medication have completed and passed an appropriate medication course, although the manager is looking at arranging an update for all appropriate staff. The manager carries out assessments (this as part of the supervisory process) to ensure each member of staff is competent to handle, record and administer medication properly. Staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care, this seen to be the case through Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 12 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. Residents were clear that the staff did not compromise their independence and they were encouraged to carry out tasks for themselves wherever possible, this reflected in care plans. 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, this to be addressed within the building works that have now commenced. Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices about their life style that are respected by staff. Social, educational, cultural and recreational activities meet individual’s expectations. Residents have access to a range of meals that provide nutrition and are enjoyable. EVIDENCE: Staff are aware of the need to plan routines and activities around the wishes of the residents and there was documentation in case files to show that there had been consultation with residents around what these wishes were, with choices documented confirmed as accurate by the individual resident. There was evidence of staff providing some flexibility in the way they provided care to meet with residents wishes, this in accordance with care plans and as supported by the homes policies and procedures. There was some documentation of residents preferences in respect of activities documented in case files, and a pictorial activities programme displayed in the homes dining room, with the activities seen taking place correlating with this Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 14 programme. Individual records in respect of those residents whose care was tracked showed that there was some variety in what activities were offered, with these fitting in with the wishes of those residents spoken to. Residents were clear that whilst activities maybe available they were free to participate or not dependent on their choice at the time. Staff were however seen to encourage residents to become involved. There are activities, which present the residents with the opportunity for gentle exercise such as skittles; music with movement and a craft organiser visits the home once a week. The home has an in house church service once a month. There was evidence of the home arranging events where relatives were encouraged to participate, such as seasonal parties throughout the year. The home has open visiting arrangements, the only restriction to avoid meal times, 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 were seen to be able to have their own personal possessions in their rooms within health and safety or space considerations. There was documented evidence of some residents or their representatives been made aware of their right to access records or information held about them by the home. The food in the home was seen to be of good quality, well presented and meeting the dietary needs of the residents. The menu, which is now supported by pictorial images of meals, showed that a varied diet was available consisting of foods that met residents cultural preferences. 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. Residents confirmed that the food was easy to digest and that choices not documented on the menu were available if requested. The cook was knowledgeable as to how to fortify resident’s diets without the need to use prescription supplements, although these were available where needed. The cook also showed an enthusiasm as to providing a good quality service and this reflects in her recent achievement of a vocational qualification in hospitality services. Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have confidence that these will be listened and responded to. Management and staff are aware of what constitutes abuse and the necessary steps that should be taken to prevent it. EVIDENCE: The service has a complaints procedure that 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. Residents and relatives spoken to stated they were happy to bring issues to the attention of management and were confident these would be dealt with. The home has access to the local authorities vulnerable adult procedures and the manager and staff were aware of the steps to take if witnessing abuse, with an expressed commitment to challenging what they considered bad practice. One complaint has been received by the home since the time of the last inspection and the home was seen to respond within the prescribed timescales, with detail kept of the actions the home had taken in response to the issues raised. Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 16 Training in adult protection has been provided to staff with identification of those staff needing this input within the homes training plan and individual staff appraisals. The manager stated she was still looking into the possibility of arranging training for staff in restraint this to fit in with planned distance learning course in dementia through a local college. Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a comfortable and clean environment, with the planned refurbishment of the building expected to address identified shortcomings related to the homes layout and décor. EVIDENCE: The service provides a homely environment although the premises would benefit from redecoration and refurbishment, which was stated to be planned following the completion of an extension to the home, this now commenced with the builders seen to be on site. The manager stated that when the extension is complete the whole home is to be redecorated and refurnished. This is to include the fitting of a new heating system as it was stated this needs overhaul, this evidenced by the lack of hot water mid morning on the Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 18 one day of the inspection, and comments from residents as to other instances where this occurred. The manager did however call out the plumber to address this issue at the time the inspector was at the home. 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 bring in items of there own furniture. They are able to spend time in their rooms whenever they wish and can choose where to sit in communal areas. Residents expressed satisfaction with the accommodation although felt that redecoration would be beneficial and were aware of the plans for this. The home was however seen to be clean. 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. The provision of larger, more suitable toilets was seen to have been addressed in the plans for the extension of the home. Residents asked did not hold keys to bedroom doors, although were unconcerned as to this matter. There was however documentation in case files to show that this was explored with the resident and that it was there choice not to hold keys. Again residents asked were content with the amount of furniture provided by the home in their bedrooms, but some felt some items would benefit from replacement, this again stated by the manager to be planned post extension work. There has been one recent outbreak of an infection at the home and based on the steps taken at the time the home was seen to have responded appropriately, with contact made with the Health Protection Agency. Liquid soap and paper towels were seen to be available for staff use as was protective wear such as gloves and aprons, these seen to be used by staff whilst carrying out personal care. Issues in respect of legionella risk assessment have now been addressed as evidenced by sight of risk assessment carried out by a contractor employed for this purpose. There are some other areas that present a potential risk to residents including some hot water pipes not covered. There was also damage to the flooring in the kitchen, which whilst repaired was seen to be coming loose, this presenting staff with a potential tripping hazard and a trap for dirt. A number of hot taps in bedrooms were found to be loose, swivelling in the sink base when turned on or off. Whilst there is a need for refurbishment of the main body of the home the carrying out of this work following the major building alterations, as opposed to before it, presents as a logical approach. There was seen to be a basic risk assessment in respect of the building works completed by the contracted builders. Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 17,28,29 & 30 Quality in this outcome area is adequate 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 and insight into developing training targets based on residents needs has improved. Poor Recruitment procedures conflict with stated practice and potentially put residents at risk. EVIDENCE: People using services are generally satisfied that the care they receive to meet their needs, and all residents and relatives spoken to were positive as to the availability of staff and their attitude and approach. Staffing levels at the time of the inspection were seen to be sufficient for the number of residents living at the home, this based on their dependency and needs. There are enough qualified (NVQ level two or above), competent and experienced staff to meet the health and welfare of people using the service. Staffing rotas as seen take into account the needs and routines of the people using the service. Sight of staffing during the course of the inspection evidenced the accuracy of the staff rotas. Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 20 The service recognises the importance of training, and the manager is working hard to deliver a programme that meets any statutory requirements and the National Minimum Standards, this with some success as the majority of staff have training in the majority of mandatory areas. The manager is aware that there are some gaps in the training programme and evidenced that training was booked or spoke of plans to address these gaps. The service is getting better at recognising when additional training is needed, and based on the managers comments is able to source specialist training providers to assist with the provision of this training. All staff spoken to were clear regarding their role and what is expected of them. People using the service report that staff working with them are good at their job and know what they are doing whilst meeting their needs. Outcomes of reviews with social services also indicated that resident’s needs were being met. The service has a recruitment procedure that needs revision to ensure it meets the regulations and the National Minimum Standards; this as there is no reference to the need to obtain a POVA check prior to recruiting staff. The procedure does not however follow the steps the manager recounted, this verbal detail in accordance with the regulations and standards. The manager was well are of past difficulties encountered by the home in respect of recruitment practice and is committed to ensure these are fully addressed. As there has been no recruitment of staff since the last inspection it was not possible to directly evidence this however. The home does not use any agency staff, with existing staff working additional hours should this be required. This does assist with the consistency of care. Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 & 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The management and administration of the home is developing with evidence of greater proactively with the introduction of tools that will assist in self-audit. Issues in respect of health and safety of residents have been taken seriously and addressed. EVIDENCE: The manager is not yet qualified although has extensive experience of running the home at management level and has improved her awareness of the basic processes set out in the National Minimum Standards. The manager stated that she was well supported by the homes provider with weekly meetings where any issues arising could be discussed, and where there was support available Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 22 to her. The financing of the business is the responsibility of the provider although the manager is involved with this through the business planning for the home, with clear, and simple business objectives set for the forthcoming year, a number of these with a customer focus. The manager is aware of the need to keep up to date with practice and continuously develop management skills, and foresees her forthcoming involvement in her Registered Managers Award as an opportunity to assist with this process. The home has purchased Policies and procedures “off the shelf” these in general satisfying the basic minimum requirements of the regulations and national minimum standards, although they would benefit from individualisation to reflect the exact practices and policies of the home. An emphasis on equality and diversity within the review of policies and how opportunities are promoted for residents that maybe disadvantaged is to be encouraged. Quality assurance monitoring has been developed since the last inspection and the manager is using a tool that has a basis on regulations and national standards. The evidence used within this tool is drawn from the comments of the service users and others (this summarised in an overview of findings from the last round of questionnaires issued). The manager has sought support from the local authorities commissioning department in formulating this tool. The provider as stated has weekly meetings with the manager and staff felt able to approach the former if needed. The CSCI has not received any copies the reports from the providers unannounced monitoring visits however as is required by legislation (once a month). There was evidence that the staff are gradually reading and signing to say they have read the homes policies and procedures, and the manager was advised to use supervision, meetings and such like as an opportunity to ensure staff are kept abreast of any changes within these. Staff in discussion did show an understanding of key issues however, and had an awareness of where the policy/procedure folder was kept for reference. Staff meetings take place at least six monthly, the provider always stated to be available for these. Supervision sessions are regular and staff find them helpful, with these sessions been based on the manager or seniors observing staff practice then having a one to one session to discuss the observation. Notes are taken of meetings and sessions. 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. Issues raised by Environmental services in respect of some health and safety matters have been addressed by the home and there was seen to be better recording of accidents, these matching all other entries in those records examined. Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 4 X 3 Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 Requirement The registered provider must ensure the following works are attended to; The taps in upstairs bedrooms are to be secured, this so residents can grip them without them turning. The kitchen flooring is to be repaired/replaced, this to remove any dirt trap and potential tripping hazard for staff. That there is a system for monitoring the supply of hot water to bedrooms until such a time as the heating system is replaced/upgraded. The registered persons must ensure that the homes recruitment policy is reviewed to ensure it references the need to obtain POVA checks for staff prior to employment, this to ensure residents are safeguarded. The provider must arrange for unannounced, monthly, regulation 26 visits to be made to the home to interview service users, relatives and staff in DS0000025035.V342422.R01.S.doc Timescale for action 31/07/07 2. OP29 10,19 31/07/07 3. OP33 26 31/07/07 Park Lane House Version 5.2 Page 25 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. The purpose of these reports is to update the CSCI of the homes progress and ensure any issues affecting resident’s welfare are highlighted. The report can take the format of a summary of the provider’s findings from their weekly visits to the home as long as one is unannounced. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP2 Good Practice Recommendations The registered provider should review the statement in the contract that indicates residents are not the homes responsibility outside the home. This needs to clarify that this is when they are with relatives, not staff. To develop the homes complaints procedure in large print and pictorial format. To display the photos of all staff in a communal area so as to assist residents and relatives to identify them by name. The registered provider should ensure that all hot water pipes present no risk to residents following the upgrade of the homes heating. The registered provider manager must ensure that all staff continue to read, sign and date all written policies and DS0000025035.V342422.R01.S.doc Version 5.2 Page 26 2. 3. 4. 5. OP16 OP18 OP25 OP31 Park Lane House 6. OP32 procedures operational within the home; this after they have been reviewed so as to ensure they match the homes individual and specific practices. The registered persons should review the homes policies in respect of Equality and Diversity and how opportunities are promoted for residents that maybe disadvantaged. Park Lane House DS0000025035.V342422.R01.S.doc Version 5.2 Page 27 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. 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