Inspection on 07/06/05 for Park Lane House

This inspection was carried out on 7th June 2005.

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

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

Other inspections for this house

Park 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 15/11/05

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 Announced 7 June 2005 th 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 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 E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Park Lane House Address 163 Tipton Road, Sedgley, Dudley, West Midlands, DY3 1AA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01902 884967 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 (2), Physical disability over 65 years of age (18) Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1st February 2005 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 problems would be experienced by heavily dependent people and wheelchair users. The home does have a passenger lift. There are 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 and 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 E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection began at 9.00am and concluded at 7.15pm. The plan for the inspection was to assess performance against Standards 8(health), 12(social activity), 14(autonomy and choice), 18(protection), 19(premises and 27(staffing complement) as these are core standards that were not assessed at the previous inspection. In addition it was planned to reassess areas where there was significant concern arising from the last inspection. These areas are Standards 30 (staff training), 29 (recruitment), 36 (staff supervision) and quality assurance. The Inspector decided not to reassess medication in full as this was assessed at the previous inspection and whilst there are some concerns it is planned to return to the home with a pharmacy Inspector who can undertake a complete audit of practice. It was also planned to assess those previous requirements relating to the Standards determined above with a view to covering as many others as time would allow. Time restrictions meant that not all were assessed as planned but extra monitoring visits are scheduled and any omissions can be assessed then. The Inspector was able to speak to the Proprietor / manager, Deputy manager, a staff member, a relative and 3 residents in detail during the course of the inspection day. In addition records were assessed and case tracking was undertaken to assess how the home is meeting the identified needs of residents. It is planned to hold a meeting with the proprietors on 1st August 2005 to assess their plans for the ongoing improvements required. What the service does well: Residents and relatives have always spoken highly of the service offered. Residents and relatives at this inspection praised the approach of staff, the atmosphere within the home, the food and there was a high level of satisfaction with individual bedrooms. A relative spoken to praised the home highly and could not think of any areas where the home could improve. She said of her mother who had lived at the home for 4 years ‘ it’s lovely, the atmosphere is great, everyone is really friendly and helpful, the staff are lovely’ and ‘ I couldn’t wish for her to be in a better place’. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 6 A resident said that ‘the breakfast and dinners are very good’ and said that there was nothing she would change. She gave examples of being able to make choices about what she wears and rising and retiring to bed times. She said that most staff are very nice and some are very patient. She said that she feels safe. A further resident said that she was ‘more than happy’ with the service provided and was particularly pleased with the improvements in her health since admission to Park Lane House. Her observed demeanour would support this. Some activities are provided that meet the social needs of some service users. What has improved since the last inspection? The outcomes from this inspection were in part for the first time encouraging. At the last inspection the Inspector advised that the home must start to meet more requirements that it is given and this has happened on this occasion. The Deputy manager said that she had been able to work from the last inspection report for the first time to work towards making improvements required and work had been delegated. There was a greater understanding of improvements required and the inspection process benefited from this. It was disappointing that immediate requirements needed to be issued for significant mal practice in relation to recruitment and adult protection. The environment continues to improve. On the day of inspection new guttering and fascia boards were being fitted enhancing the physical appearance of the home for residents and ensuring appropriate essential maintenance. Many previous requirements in respect of improvement to the premises have been judged as met at this inspection, which has enhanced the environment by minimising the risk of infection and the risk of medication errors for self medicating residents through the provision of lockable facilities in some bedrooms. The provision of locks on bedroom doors for residents will support privacy and choice for residents too. The home has also developed the system it uses to seek feedback from residents and relatives about satisfaction with the service provided and now needs to evidence how feedback is being acted upon. Training and systems to support staff training have also considerably improved since the last inspection. The enhanced knowledge and skills of staff as a result will better prepare them to meet residents needs. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 7 Some areas of medication management have improved and information is now provided to residents through the provision of a daily menu board and written information about local advocacy services. What they could do better: There are significant concerns about the systems in place to protect vulnerable adults. The home is currently failing to adequately take steps to promote the protection of residents. Policy, procedure and understanding of adult protection processes are all inadequate. This is underpinned by unsafe recruitment processes, which have put residents at risk and an inadequate physical intervention policy. The management at the home must develop its understanding of the categories of residents it is registered to care for to ensure that the needs of residents admitted and cared for can be met and comply with the law. The home is not for example registered to care for residents whose primary need is dementia. Another resident said that she never goes out and would like to do so. Staff said that the manager takes her out occasionally but there was no recorded evidence of this in records looked at that began in January 2005 (6 months) Work continues on care plans but further development is required to ensure that all assessed needs of residents are known, planned for, acted upon and monitored. It was disappointing that previous requirements issued to improve safety for residents have not been met. For example radiators have not been covered to protect residents from the risk of burns. This has been required for a considerable time. The Commission for Social care Inspection has been previously informed in writing that radiators would all be covered by the end of April 2005. This has not been achieved with radiators remaining uncovered in all bedrooms (with the exception of one). Improvements are needed with medication, meeting the health care and social needs of some residents. The manager also needs to familiarise herself with methods of calculating staffing requirements based upon the dependency levels of residents ensuring that this is implemented and kept under review. The Commission for Social care Inspection will be considering further enforcement options in relation to areas not addressed for some considerable time. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 8 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 E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 9 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 Standards Statutory Requirements Identified During the Inspection Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 10 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 standard(s) 1 - 5 Information systems in place are not sufficient to help and support a resident’s choice of home which meets their needs. The home accommodates people it is not registered to care for. EVIDENCE: These Standards were not fully assessed but previous requirements have not been met although some progress has been made. Omissions remain in the Statement of Purpose (room sizes for example), a new resident spoken to had not been issued with a service user guide which given that she was admitted, as an emergency would have supported the settling in period. There was no other evidence that she had been informed within 48 hours of key aspects, rules and routines of the home. She has furthermore not been issued with a letter confirming that her needs can be met by the home. A contract of residency for her could not be located. A community care assessment had been undertaken and provided by the placing social worker. The home has not met a previous and ongoing requirement to ensure that all residents placed within the home comply with its current categories of registration. The manager explained that her registration certificate states incorrect categories but this should have been brought to the attention of the Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 11 Commission for Social Care Inspection immediately for investigation. The Inspector spent some time explaining again the requirement and action must now be taken as a priority. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 12 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 standard(s) 8 There is a need for an improvement in systems that will better support health provision. EVIDENCE: A relative and all residents spoken to were happy with how their health needs are managed. One resident was delighted with how her health has improved since admission. A relative said that the home always communicates any changes in health condition to her. Everybody including staff spoken to had no concerns about health management and felt that the GP is called quickly and appropriately. The notes of one resident show that in the last three month period the GP has visited 3 times. A relative said her mother is always clean and her clothes well laundered. A gentle fitness class is held once a week and a relative said that staff ensure that her mother has regular short walks. Care plans continue to require further development in respect of routine health screening (dentist, opticians, hearing tests) and the specific health requirements of individual residents. For example, one resident has a hiatus hernia but the care plan does not detail care required either in terms of screening appointments, signs and symptoms, when to refer for medical help Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 13 or dietary implications. There have been 3 resident accidents since August 2004, two were falls by the same person. The Inspector was told that night checks have been increased to hourly to minimise the risk. This is not reflected in this resident’s plan of care and is not evidenced by night records, which are clearly completed at the end of the shift. Care plans must be more specific about night check needs. Pressure sore assessments and nutritional assessments and regular weight records are available. No residents currently have pressure sores. Weights had increased for those residents whose files were sampled. The chiropodist visits regularly. The home is registered to care for 2 residents with mental disorder and these beds are occupied. Care plans to support residents anxiety state were detailed and appropriate. There have been previous requirements in relation to medication not all of which have been reassessed on this occasion. Those that have been assessed have been mostly met. Support visits from the supplying chemist are now being undertaken and delivered drugs are being counted in and recorded. Work has been undertaken to review the medication policy and improvement is evident. There remain however some omissions the exploration of which has highlighted poor ordering of medication practice. This is supported by a previous requirement to investigate a situation where the home had run out of a prescribed drug for a resident. The investigation has shown that the chemist is ordering from the GP rather than the home. The chemist is then picking up the prescriptions from the GP. This is preventing the home from managing an area for which they hold responsibility and denying the home the opportunity to check that the Doctor has prescribed that which has been ordered. It also denies the home control over stock management. This is a new requirement. The Inspector intends to request an audit by the Pharmacy Inspector. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 14 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 standard(s) 12, 14 The home is meeting the social needs of some, but not all residents. Some group activities are provided but the individual interests of residents are not addressed. EVIDENCE: Group activities continue i.e. bingo and the craft lady visits weekly, as does the fitness instructor. Photographs were available showing residents making Easter bonnets. Discussion with staff showed that they require support to consider alternatives to the traditional model of group activity in residential homes. The Inspector was told that one resident doesn’t join in the group activity because she is very old and an other lady doesn’t join in because she is always asleep. Activities that appeal to these people other than group activity must be explored. Residents who are able to undertake individual activity e.g. knitting do so and there is recorded evidence of this as well as the inspector having had the opportunity to observe this. The home must now concentrate its efforts on those who are less able to undertake activity independently and those who would prefer not to join in with group activity. One resident told the Inspector that she had previously Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 15 enjoyed gardening. The home must think creatively as to how this interest could be encouraged within the confines of residential care e.g. gardening programmes / videos, visits to garden centres / garden shows / propagating seeds / looking after houseplants etc. Whilst a staff member informed the Inspector that a game of skittles had been played as the activity for the day this is not considered sufficient and the Inspector observed residents throughout the day sitting without moving and sleeping with no observed group or individual activity. One resident said that she would love to go out and although staff said that she is taken out from time to time there was no record of this in her very detailed activity-monitoring sheet. Six months of records were assessed. One resident attends a place of worship regularly as the members of that church support her to do so. Staff and residents spoken to said that residents can get up and go to bed when they like and that there is flexibility over when baths are taken etc. A relative confirmed that residents are encouraged to do things for themselves, that the home does not manage any aspect of her mother’s finances and that her mother had been able to bring personal items to the home to personalise her room. Since the last inspection information about advocacy schemes to support residents has been made available within the home. Also a menu board has been provided in the dining room, which is another improvement since the last inspection. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 16 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 standard(s) 16, 18 Practice in relation to complaints has improved. Systems in place do not support the protection of residents or staff to take appropriate action in the event of an allegation of mal practice or abuse. EVIDENCE: The Inspector was pleased to see that the home is now recording any complaints received and action taken in response. The home has received 2 complaints which are recorded. Both of which were upheld by the home (this was not noted on the complaints record and must be). One was in relation to lost dentures and the other in relation to an incident between 2 residents. The dentures were not found but action was taken to replace them and it is noted that the complainant was satisfied with action taken. The second was appropriately responded to i.e. medical advice was sought, Social Services were informed and attended a meeting about the incident. As this was an adult protection incident the Commission for Social Care Inspection should have been informed without delay as a regulation 37 notice this did not happen. The home offered to move the ‘victim’ to another room but the decision was taken by the family for the resident to move to another home. A complaints policy is available and is available for residents although the format should be more user friendly and suggestions were made. The one complaint was met within timescales but due to delays outside the homes control, the second complaint was not. Records must more clearly indicate when complaints are resolved. The Inspector suggested that it would be good practice to write to the complainant summarising the complaint, the investigation, and options considered and agreed and whether the complaint has been upheld. This letter should include the details of the Commission for Social Care Inspection in the event of dissatisfaction. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 17 There has been less progress in the area of adult protection. There are no national or local guidelines on the premises and the homes policy and procedure is contradictory and gives misleading advice particularly in relation to residents who may not want alleged abuse reported. The policy does not define abuse and does not state that in the event of an allegation that the Commission for Social care Inspection must be informed. An immediate requirement was issued to ensure that remedial action is taken without undue delay. Staff are beginning to receive training in adult protection. The homes physical intervention and restraint policy has not been reviewed as previously required. This means that staff are not sufficiently guided to act in a way that is in the interests of residents and compromises residents safety. Residents are furthermore not protected by the homes recruitment practice and an immediate requirement was issued in respect of this. Residents voting wishes are not recorded. A new resident who moved in prior to the General election in May this year said that although she would have declined she had not been asked if she wanted to vote. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 18 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 standard(s) 19 Park Lane is homely and residents express satisfaction with their environment. Improvements to the environment continue to progress to better meet residents’ health and safety. In areas where there is significant risk progress is too slow (e.g. radiator covers) risking residents safety. EVIDENCE: Along with training and quality assurance, the Environment is an area that has most significantly improved since the last inspection. It was pleasing to for the first time see a maintenance programme, which was being adhered to. The provision of radiator covers had not been included in the maintenance and renewal programme. Radiator covers have been provided in the upstairs corridor but in only one bedroom, which is an improvement since the last inspection but does not totally meet the requirements of the previous requirements and immediate requirement issued last time. In response to the immediate requirement issued at the last inspection the manager submitted an action plan to say that radiator covers would be fitted by the end of April 2005. This has not been achieved. Enforcement action could be considered to achieve completion of this task. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 19 Other previous requirements have been met e.g. cupboards are now available in toilets and bathrooms, a lockable facility has been provided for three residents who hold their own medical creams. The cupboards provided are of a good quality and residents reported being pleased with them. It remains now for all other residents to be supplied with the same. The controlled drugs cupboard is now secured. Locks have been fitted to the remaining bedrooms that needed them with a thumbscrew mechanism on the internal side of the door. Keys have not yet been issued to most residents (one resident currently holds a key) but individual wishes have been sought and recorded. One resident told the Inspector that she was aware that a key is being arranged for her. This is progress. A lockable cupboard has also been provided in the kitchen to keep hazardous chemicals safely. Damaged ceilings have been repaired and the décor has now been made good in two bedrooms. Bath mats are now clean and a showerhead has been replaced and is now included on a cleaning schedule. A mechanical disinfector for the effective cleaning of commodes has not been obtained. The manager explained that there is not sufficient space but she plans to address this in proposed extension plans, which she hopes will be submitted by the end of the year. The home remains homely and clean and is fresh smelling throughout. The Environmental Health Department are currently working with the manager at the home to ensure improvement in some areas relating to Health and Safety. The home is awaiting a report from her last visit. A previous requirement to comply with areas of contravention identified in the last Fire Inspection report (October 2004) has the manager said, been complied with but evidence that the fire doors were now correctly aligned could not be provided as the Manager said that the handy man had undertaken this task. The manager must recontact the Fire Department to establish whether the handy man is considered sufficiently competent to undertake this task. The grounds are tidy and safe. New guttering and facia boards were being fitted on the day of inspection Maintenance records were not assessed at this inspection and will be assessed at the following inspection. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The Proprietor / manager is failing to take appropriate steps to minimise risk to residents through inadequate management of recruitment processes. Training systems, provision and uptake of training has improved significantly since the last inspection and performance against this Standard is now promising. This will better support staff to effectively meet the needs of service users. EVIDENCE: Recruitment documentation for 3 new staff members was assessed and is insufficient to adequately protect residents; New Staff Member 1 There was an application form with a photograph and a self-disclosure in respect of any previous offences. Employment history is explored and reasons for leaving employments. There was a job description (not signed), evidence of interview and a signed medical questionnaire and signed contract of employment. This is good practice. There was a copy of the birth certificate. There was not a CRB (Criminal Record Bureau) check or POVA (Protection of Vulnerable Adult) first check. There was insufficient identification and no risk assessment. The two written references on file had been obtained after the start date of 23.2.05 (a date taken from the rota as her start date was not recorded on file). One reference was dated 1.3.05 and the other 3.3.05. Neither reference was from a former employer. The Commission for Social Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 21 Care Inspection had not been informed of the intention to commence this staff member in employment prior to receipt of satisfactory CRB/POVA checks and no answer could be given as to any extenuating circumstances that necessitated an urgent start date. It was agreed that there were not any extenuating circumstances. This new staff member had been employed as a night care assistant whereby she is subject to less supervision and more than 3 months after commencing in employment she has not started the mandatory TOPSS Induction course. In addition she has not worked in the care industry before working at Park Lane. This is unsafe practice and places SU’s at increased risk. Mrs Ramdoo, the Registered Manager and Proprietor said she was aware that she was at fault and apologised. The situation was the same for two other new staff members started in employment since the last inspection. Portable CRB’s had been accepted by the home although this is no longer acceptable, and POVA checks had not been obtained (nor sent for). The details of none compliance for the second and third new staff members have been included in the immediate requirement letter to the Proprietors / manager but are not repeated in this report. The manager, Mrs Ramdoo, concluded that she would stop all three staff from working until all satisfactory documentation is obtained. One staff member was sent home during the course of the inspection. Training systems have improved. There is now a team matrix identifying training achieved and planned. A date of when the training has been achieved needs be recorded to help to plan when refresher training is required. Some Certificates were available (the Inspector saw 3 for 3 staff members) which is an improvement on previous inspections as none were available. One staff member whose file was sampled has, since the last inspection, undertaken infection control, food hygiene, moving and handling and Fire Safety training. The manager said that they are still awaiting some certificates from the training provider. The Inspector was informed that the management have discussed the need for training with staff and staff have embraced new opportunities being offered to them. The staff contract has also been amended to state that 3 paid days training per year will be provided to comply with the requirement from the last inspection. This is now included in the contract for the new staff and was seen by the Inspector. The contracts of existing staff were not assessed to see if they have been issued with a revised copy. The matrix now shows that: 0ut of 20 staff 5 have done health and safety training, 15 have not. 9 staff have done moving and handling training, 11 have not 8 staff have done food hygiene training, 12 have not 7 staff have done infection control training, 13 have not 8 staff have done dementia training, 12 have not (the home is not registered to care for residents with dementia) Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 22 Progress has been made with the provision of induction training to TOPSS (Training Organisation for Personal Social Services) Standard. This has not been in place at previous inspections. This inspection has shown that some new staff have started although it hasn’t been completed within timescales and one new staff member who is totally new to care hasn’t made a start 4 months after taking up post. The Inspector suggested to the manager that she needs to consider how she is supporting staff to gain the knowledge they need to effectively pass the induction standards and also expressed concern that they are not evidencing their knowledge. The manager said she will give this consideration. There remains some work to be done to ensure that all staff have undertaken all training but the Inspector is satisfied with the progress made and the fact that the planning and evidence system is greatly improved. Dates of training must be included on the matrices. The manager reported that the home is fully staffed with no staff vacancies. Three staff are being maintained on each shift with 2 staff at night. The deputy manager reported no difficulties covering shifts and even given the decision to suspend the three new staff pending receipt of appropriate checks there was no concern as to how these shifts would be covered. Staff said they felt there was enough staff although they were a bit pushed when the home is fully occupied (currently 4 resident vacancies). A relative spoken to said she had no concern about staffing levels and written feedback given to the Inspector by relatives prior to inspection did not identify this as a concern. Discussion with the manager however showed that she has not considered the effect of service user dependency levels on staffing requirements and this was subject to immediate requirement. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 23 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36 Service users, staff, and relatives see the management as approachable and helpful. Performance is mixed but has for the first time showed some signs of improvement. The registered manager / proprietor has failed to discharge her responsibilities fully therefore compromising the safety and well being of vulnerable adults. EVIDENCE: Formal supervision has started now with evidence that the manager has undertaken one recorded session with each staff member (from the files sampled). The management team would benefit from training in the role and function of supervision to increase their knowledge and confidence, as it appears that the functions of supervision and appraisal are still being confused. It was however pleasing to see that a start has been made and this provides a foundation upon which to build. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 24 Quality assurance systems have improved since the last inspection. Satisfaction questionnaires have been distributed to residents and relatives and the range of questions within has been considerably developed. Previously only satisfaction levels with food were measured. The results have been collated and briefly summarised which is good practice showing a high level of satisfaction. Suggestions were made for further development e.g. the inclusion of professional visitors feedback, residents / relatives to sign all pages to give greater authenticity, distributing the summary to residents, relatives, commissioners and the Commission for Social Care Inspection and to ensure that views are sought regularly. This is the first inspection where improvement in Management of the home is in evidence. The decision to delegate some responsibility for meeting past requirements to the Deputy Manager and seniors has ensured progress and optimism that the home can improve its performance. It was disappointing that the areas that the Registered Manager took responsibility for (Recruitment, adult protection policy etc) have resulted in immediate requirements. It has long been the intention of the manager to promote the Deputy manager to Registered manager, as she does not intend to obtain the required manager qualification herself by 2005. The manager reiterated this intention at the inspection. That intention must now be acted upon as 2005 is now at the mid way point. The Deputy has NVQ level 4 and has an interview in June to commence the Registered Managers Award. At the time of writing this report an application form to apply for registration as manager has been forwarded to the home and must now be completed and returned to the Commission for Social Care Inspection for assessment without delay. A copy of the home’s business accounts were for the first time submitted at inspection to the Commission for Social Care Inspection and demonstrate that the home is economically viable. A Business plan was also available. Advise of the Fire Service has not been sought as required in respect of alternatives to wedging fire doors. However the Inspector was told that a policy decision has been made not to wedge doors and doors were not wedged on the day of this announced inspection. Therefore the requirement has been deleted but will be kept under review. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 25 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 1 2 2 1 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 x COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 2 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 x x 2 x x 2 x x Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 26 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. The registered provider must 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 Service user Guides must be issued to all residents – current and future. (June 05 not issued to service user admitted April 2005) Terms and conditions of residency should be available for all service users. ( At June 05 Contract not available for Resident admitted since last inspection The home must ensure that service users and their representatives are involved and this is recorded in the pre admission assessment. E55 S25035 Park Lane House V232393 070605 Stg4.doc Timescale for action NOT MET 31.7.05 2. OP1 5 NOT MET 31.7.05 3. OP1 5 NOT MET 30.6.05 4. OP2 5(3) NOT MET 30.6.05 5. OP3 14 NOT MET NEXT Admission Park Lane House Version 1.30 Page 27 6. OP3 7. OP3 8. OP3 9. OP4 10. OP4 11. 12(2) 12(3) The registered person must confirm in writing to the prospective service user that the home is able to meet their needs. 17, 15, 14 The registered provider manager must ensure that service and / or their chosen representative signs and dates their assessment of need and their care plan (plus any care plan reviews) to demonstrate that they are satisfied with the needs that have been identified and the content of their care plan. 15 The registered provider manager must ensure that each service users care plan is reviewed at least monthly or immediately as changes occur. Care The manager must submit in standards writing to the Commission for Social Care Inspection a list of Act 2000 S.24 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. Care The registered provider must standards apply for a variation to the Act 2000 certificate of registration for any S.24 service users accommodated 10(1) outside of their current 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 inspection need for further variation applications identified OP5 Trial visits must be offered to all residents. The offer must be E55 S25035 Park Lane House V232393 070605 Stg4.doc 14(1)(d) NOT MET 30.6.05 NOT MET 31.7.05 Not assessed 31.7.05 NOT MET NOT MET 31.7.05 Not AssessedPage 28 Park Lane House Version 1.30 12. 15 OP7 13. 15 OP7 14. 13, 14, 17 OP8 15. 13 OP8 16. 13(4)c 13(6) OP8 recorded. The detail of the trial visit must also be recorded. (New resident since last inspection was an emergency admission) The service users care plan addresses all their needs. Care plans should be reviewed at least monthly or as clinically indicated. To expand the care plan of resident diagnosed with Hiatus hernia to include health plan, dietary requirements and dietary preferences. New Requirement this inspection – June 2005 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. New Requirement this inspection – June 2005 The registered provider and manager must ensure that oral care is incorporated within the daily recording of care delivered. Occupational therapy advice is required in respect of resident FB. A behaviour management support plan must be implemented for FB. The following must be present and complete for resident LF and for all residents: · Manual Handling Assessment · Pressure Sore Assessment · Nutritional risk assessment Falls risk assessment 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 E55 S25035 Park Lane House V232393 070605 Stg4.doc Next new admission Not Met 31.7.05 30.6.05 Not Assessed 31.7.05 NOT ASSESSED 30.6.05 Not Assessed 17.6.05 Park Lane House Version 1.30 Page 29 Feb 05 17. 17(1)(a) Sch(3)(3)n 12(1) 15 OP8 Action must be taken and recorded when a resident is assessed as being at risk of pressure sores (e.g. E.W.) Required intervention must be included in the resident’s plan of care. 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. NOT ASSESSED The manager must review and expand the medication policy to include all aspects of ordering, receipt, storage, administration, disposal of medications and homely remedies. PART MET Where 1 or 2 tablets are prescribed administration must be as per written criteria and medication administration records must indicate whether 1 or 2 have been administered. NOT MET The registered provider must ensure that the homes pharmacy provider carried out a documented audit of the homes medication on a regular basis. PART MET- HAS STARTED. ONE UNDERTAKEN SINCE LAST INSPECTION 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 E55 S25035 Park Lane House V232393 070605 Stg4.doc Not Assessed 1.7.05 18. 13(1)(b) 23(2)(j) OP8 Not Met 30.9.05 Not Met 30.9.05 PART MET 30.6.05 19. 13, 17 OP9 Park Lane House Version 1.30 Page 30 20. 21. 13(2) 13(2) 24 37 OP9 OP9 22. 12(2) 12(3) 12(4)(a) OP11 23. 12(3) OP11 24. 15, 16 OP12 25. 12 OP12 26. 12 OP12 or inhalant preparations. (Including LF) NOT ASSESSED All homely remedies must be approved in writing by the resident’s GP. NOT MET The manager must seek advice about the storage of medication for respite residents. 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) The policy on supporting people 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. 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. A Service Users Life Biography, which includes detailed leisure/social interests, is recorded in their records. (Not met for service user case tracked.) 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) The care plan of EJ must be 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. NOT Assessed 30.6.05 Not Assessed Ongoing NOT Assessed 31.8.05 Not Assessed 31.8.05 NOT MET 31.7.05 Not Assessed 30.9.05 30.6.05 Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 31 27. 22 OP16 28. 12(2) 12(3) OP17 29. 13 OP18 30. 13(6) OP18 New Requirement this inspection-June 2005 The registered provider manager must ensure that the complaints procedure is produced / available in a format which is understandable to all service users. 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. To expand the policies relating to adult abuse, physical aggression and restraint to include references to the Dudley Local Authority multidisciplinary Protection of Vulnerable Adults Policy and procedures and include required involvement of the Commission for Social Care Inspection. (To obtain in addition copy of Department of Health ‘No Secrets’) To obtain the necessary local and national guidelines in respect of adult protection To review the homes adult protection policy to comply with local and national guidelines. To provide written confirmation of receipt of local and national guidelines and to provide a copy of the home’s revised policy /procedure relating to adult protection to the Commission for Social Care Inspection by 31.7.05. All staff receive training in awareness of abuse. NOT MET 31.7.05 NOT MET 31.7.05 NOT MET 31.7.05 See new immediate Requ’mnt NOT MET 15.6.05 IMMEDIAT E 31. 13, 18 op18 Part met – some Page 32 Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 3 staff have done, 17 have not 32. 13(6) 13(7) 4,16,23 OP18 33. OP20 34. 23(2)(f) OP20 35. 23(2)(f) OP23 36. 16,23 OP24 37. 16.23 OP24 38. 12(3) 12(4)(a) 13(4) 13,14,16 OP24 39. OP24 progress 31.3.05 The manager must ensure that NOT MET the restraint policy is reviewed in 31.7.05 accordance with Department of Health Guidance. The size of all bedrooms and Not MET communal rooms must also be 31.7.05 included within the statement of purpose and forwarded to the National Care Standards for consideration. Communal Space available to NOT MET each resident must be calculated 31.7.05 and included in the Statement of Purpose. This information must be sent to the Commission for Social Care Inspection. The manager must provide Not evidence that people who are assessed currently sharing a have made a Ongoing positive choice to share with each other and are offered the option of a single room when one becomes available. At Feb 05 no residents currently sharing. The home undertakes an audit of NOT MET each room recording where all 31.8.05 elements of standard 24 are met and identifying the reasons why they are not met. There are discussions with Part Met residents on facilities provided 31.8.05 and decisions made need to be recorded into the service user plan, including key holding, on a risk assessed basis. Residents must be supplied, Not Met subject to risk assessment, keys Progress to their bedrooms. Any made restriction imposed must be 30.6.05 recorded with reasons given. The registered provider must NOT MET ensure that a lockable facility is 31.8.05 provided in each of the service users bedrooms. (Provided since last inspection Version 1.30 Page 33 Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc 40. 4,5,5(b) OP24 41. 16,23 OP25 for 3 residents who hold own prescribed creams) 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 All radiators are either low surface temperature touch or have radiator covers. Upstairs corridor fitted with covers since last inspection – bedrooms remain outstanding A final date for the completion of the fitting of covers to all radiators must be submitted in writing to the Commission for Social Care Inspection by Monday 7th February 2005 at 5pm. This target date for completion must be adhered to. To undertaken a written system to minimise the risk of burning to residents from radiators prior to the fitting of covers. This must be completed by Monday 7th February 2005 at 5pm and a copy submitted to the Commission for Social Care Inspection by this same date. These were immediate requirements at Feb 05 Inspection MET A risk assessment must be carried out on all radiators and hot pipes with a programme for the fitting of suitable covers drawn up and instigated, based on the priorities identified within this assessment. (Risk assessments completed, programme not drawn up covers not fitted in bedrooms) NOT MET 31.7.05 PART MET No Progress 42. 13(4), 13(6), 23 OP25 PART MET Final date given as end April 2005-not achieved NOT MET 43. 16,23 OP25 PART MET Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 34 44. 23(1)a OP25 45. 13(3) OP26 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 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) Telephone advice provided by the Infection Control nurse must be confirmed in writing to the Commission for Social Care Inspection. The registered provider manager must produce procedures for the laundry to prevent contamination from dirty / soiled washing to clean washing. 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 The advice of the Infection Control Nurse and Environmental Health must be sought and acted upon. The rota of actual hours worked must be accurate: The registered provider manager must ensure that it is denoted on the rota the name of any staff PART MET 31.7.05 NOT MET 30.4.06 46. 13,16,17, 23 OP26 NOT MET 31.7.05 47. 13(3) OP26 NOT MET 31.8.05 48. OP26 Not met 31.8.05 NOT ASSESSED 7.6.05 49. OP27 Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 35 50. 18(1)(a) OP27 51. 18 op27 52. 18 OP28 member who is covering for another due to sickness, annual leave etc. Staffing levels must be kept under review including night staffing levels. The manager must confirm to the Commission for Social Care Inspection the staffing ratios for morning, afternoon and night, provide the Commission for Social Care Inspection with 4 weeks rotas and ensure that this information is correct in the Statement of Purpose. 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 15th 2005 at 5pm. 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) 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. The registered provider manager NOT MET See new immediate requ’mnt NOT MET See new immediate requ’mnt Immediate ongoing 53. 17, 18, 19 OP29 NOT MET Immediate Requireme nt issued Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 36 54. 17, 19 OP29 55. 19 OP29 must ensure that all staff records / documents required as detailed in standard 29 and schedule 2 and 4 of the Care Home regulations 2001 are obtained and are available on site at all times The registered provider manager must ensure that the homes staff application form is amended where it states ‘ references should not be from former employer ‘ to at least one reference must be from the previous former employer. To take immediate action to protect residents and confirm action taken in relation to the 3 new staff in writing to the Commission for Social Care Inspection. All recruitment documentation must be in place for existing staff and prior to the commencement of new staff as per Schedule 2. Following assessment of recruitment documentation for existing staff the adequacy of the checks in place must be confirmed in writing to the Commission for Social Care Inspection. It must be confirmed in writing to the Commission for Social Care Inspection how it is intended to improve recruitment practice. All written confirmation must be sent to the Commission for Social care Inspection on 8th June 2005 by 5pm. All staff receive a minimum of three days paid training each year. NOT MET – PRIOR TO NEXT APPOINTM ENT Immediate 56. 18 OP30 PART MET – progress made. Page 37 Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 57. 18 OP30 To reassess at end of 12 month period – February 2006 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 The home’s induction and foundation training meets National Training Organisation standards. · 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 All staff must be provided with up to date training in the care of diabetics. To be booked by date set Staff and managers must be provided with tissue viability training. PART MET 31.8.05 58. 18 OP30 PART MET 31.8.05 Part met (no dates) 59. 18 OP30 Part met. Progress – no dates Progress 1.4.05 – 1.4.06 Not Met next appt Not Met next appt 60. 18 OP30 NOT MET 30.9.05 NOT MET 30.9.05 61. 18(1)(c)(i) OP30 Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 38 62. 18 OP31 The manager holds an NVQ 4 (or equivalent). (Manager has not enrolled on a course At June 2005 Deputy manager nominated for this course) The registered provider manager must ensure that all staff read, sign and date all written policies and procedures operational within the home. 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. The manager must submit to the Commission for Social Care Inspection an Annual Development Plan for the home by the date set. Care staff receive formal 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 Where staff have identified support needs this must be risk assessed and control measures agreed as part of the supervision process. The manager must ensure that 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 Not met No Progress 2005 Not Assessed 31.7.05 NOT MET 31.8.05 NOT MET 31.7.05 63. 17, 18 OP33 64. 24 OP33 65. 24 OP33 NOT MET 31.8.05 66. 18(2), 21 OP36 NOT MET (Within 12 months of inspection sept o4 September 2005) 67. 18 OP36 Not Assessed 30.6.05 Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 39 68. 17(3)(a) 37 OP37 69. 13,23 OP38 70. 13,17,23 OP38 71. 13 OP38 72. 13,18 OP38 be evidenced. The registered provider manager must ensure that all staff receive one to one formal supervision as per standard 36. 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) 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. 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. 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. All staff receive annual moving and lifting training. (Certificated evidence that some staff have undertaken since last inspection The manager must risk assess the toilet on the first floor due to Immediate at Sept 04 NOT MET Not met at June 05 NOT ASSESSED 30.6.05 Not Assessed 30.6.05 Not Evidenced – report awaited. Part met – 31.9.05 73. 13(4) 23(2)(a) OP38 Not Assessed Page 40 Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 23(2)(j) 74. 13(4) 37(1)(e) 13(1)b) 12(1) 13(6) OP38 75. 24(3)c(i) 23(4)(d) 13(4) 23(4) OP38 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. Action must be taken if the regular taking of residents weight shows rapid weight loss or weight gain – no issues identified June 2005 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. 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. (3 ACCIDENTS SINCE August 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 30.6.05 NOT MET 31.7.05 .PART MET30.6.05 Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 41 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. 6. Refer to Standard OP3 OP3 OP12 OP28 OP31 OP2 Good Practice Recommendations 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 registered person ensure that a recorded assessment is undertaken that details service users capabilities of selfadministration of medication. 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. The manager holds an NVQ 4 (or equivalent). Trial periods must be for 12 weeks. This must be stipulated in the terms and conditions of residency contract and amended from 28 days. Park Lane House E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 42 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen 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 E55 S25035 Park Lane House V232393 070605 Stg4.doc Version 1.30 Page 43 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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