CARE HOMES FOR OLDER PEOPLE
Park Manor 8 St Aldhelms Road Branksome Park Poole BH13 6BS Lead Inspector
Amanda Porter Unannounced 31 May 2005 10:00 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 Manor D55 S4055 Park Manor V220982 240505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Park Manor Address 8 St Aldhelms Road, Branksome Park, Poole, Dorset, BH13 6BS 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) 01202 764071 01202 765505 Park Manor Ltd Mrs Janice Scanlon CRH 37 Category(ies) of OP - 37 registration, with number of places Park Manor D55 S4055 Park Manor V220982 240505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23 November 2004 Brief Description of the Service: Park Manor is situated in a residential area of Branksome Park. The local area has a range of shops, a post office, library, public house and other leisure facilities. Public transport is accessible with bus routes and a train station nearby. Park Manor is a large house built in the late nineteenth century. Many of the original features are incorporated into the current building, which has been extended and adapted to accommodate older people. The home has substantial grounds, surrounded by mature trees and shrubs. The gardens are kept to a high standard. Accommodation at Park Manor consists of single and double rooms for service users, all with en-suite facilities; a passenger lift provides access to the first and second floor. Spacious communal areas are available to service users and include two sitting rooms, a large dining room and a smaller dining area. A large Victorian conservatory overlooks the well-maintained gardens. There is also a small interview room which is available to service users should they wish to receive visitors in private in an area other than their bedroom. The back of the house has been extended to provide 12 self contained apartments, each with its own front door and which include a sitting room, bedroom, bathroom with toilet and a small kitchen area. A lift operates on all 3 floors of the apartment block. The care, catering and laundry services of the main house also service the apartment block.
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This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the afternoon of the 31st May 2005 and took a total of three and a half hours. The purpose of the inspection was to review the requirements and recommendations made in the last report and to assess key standards. The registered manager, Mrs Janice Scanlon, was on hand throughout to aid the inspection process. Six residents and three members of staff were spoken with and asked their views on the home. Comments from service users included “Staff are excellent – couldn’t do better.” “Staff are very good at meeting my needs.” They said their right to privacy was respected and should they choose to be on their own they could. Staff said that they thought they gave a good service to residents and that the home was well run. They had been given training opportunities to ensure that the care they gave was of a high standard. Some documentation was reviewed, including care files, personnel files, policies and procedures. A tour of the premises was undertaken. What the service does well: What has improved since the last inspection?
Since the last inspection the home has met one requirement and two recommendations that were made in the last report. The pre-admission assessments seen were thorough and assurance was given that needs could be met. Care planning documentation gave staff the information they needed to deliver a high standard of care to the residents. Residents said they felt involved in their plans of care.
Park Manor D55 S4055 Park Manor V220982 240505 Stage 4.doc Version 1.20 Page 6 Maintenance work continues and most of the radiators were now covered to minimise the risk of any burning or scalding. Risk assessments were in place for those radiators not yet covered. During the inspection the top corridor was being painted and the colour had been chosen by the residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Park Manor D55 S4055 Park Manor V220982 240505 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Park Manor D55 S4055 Park Manor V220982 240505 Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 3. Standard 6 is not applicable as the home does not provide intermediate care. Prospective residents do not have sufficient or correct information to make an informed choice about whether to move to Park Manor. New residents move into the home having had their needs assessed and been assured that these needs will be met. EVIDENCE: Although the manager said the service user guide and statement of purpose had been updated an old version, which current residents referred to, was on display in the main entrance hall. This was two years old and gave out of date information. Three pre-admission assessments were seen on file. The assessments were thorough and involved the resident and their representative where appropriate. They formed the basis on which a care plan could be made. Residents said they were told that their needs could be met.
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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) 7, 8 & 10 There is a clear, consistent care planning system in place, which provides staff with the information they need to meet residents’ needs. Residents felt that staff were kind and caring, treated them with respect and upheld their right to privacy. EVIDENCE: Four care files were reviewed. They contained care plans, which accurately reflected the care given to the individual residents. There was evidence that residents and/or their chosen representatives were involved in the development and review of the care plans. Residents said that they were treated with respect and kindness and their right to privacy was upheld. They felt that their needs were met very well. “Staff are excellent – couldn’t do better.” Some said their right to privacy was respected and should they wish to be on their own they could. Relevant assessments such as moving and handling, nutrition and risk of falls were held on file and reviewed regularly. Where risk assessments identified a need for specialist equipment this was provided. Visits from health care professionals such as GP, district nurse, optician and chiropodist were recorded in the care files.
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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) These standards were not assessed during this inspection. EVIDENCE: Park Manor D55 S4055 Park Manor V220982 240505 Stage 4.doc Version 1.20 Page 11 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) 18 Procedures for responding to suspicions of abuse are not held in accordance with Department of Health guidance therefore any allegations of abuse cannot be managed effectively. EVIDENCE: Park Manor has a policy available to staff which deals with the action required in responding to suspicion or evidence of abuse. This policy did not make clear that in the event of any allegation being made staff must consult with the local Dorset Social Care and Health agency and refer to the “No Secrets” guidance provided by that agency. Park Manor D55 S4055 Park Manor V220982 240505 Stage 4.doc Version 1.20 Page 12 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) 25 The standard of the environment within the home is good providing residents with an attractive, homely and safe place to live. EVIDENCE: Since the last inspection maintenance work had continued and most of the radiator were now covered to minimise the risks of burning or scalding. Risk assessments were in place for the remaining uncovered radiators. Rooms were seen to be naturally ventilated. Lighting was domestic in character. During this inspection the top corridor was being painted and the colour choice had been made by the residents. Park Manor D55 S4055 Park Manor V220982 240505 Stage 4.doc Version 1.20 Page 13 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) 29 Robust recruitment procedures are in place to protect residents from the risk of unsuitable staff working at the home. EVIDENCE: Four • • • • • • • personnel files were seen. They all contained: Completed application forms Two written references Enhanced CRB checks Terms and conditions of employments Documentary evidence of any relevant qualifications Proof of identity A record of the interview Park Manor D55 S4055 Park Manor V220982 240505 Stage 4.doc Version 1.20 Page 14 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 & 35 The organisation of the quality monitoring system needs to be better defined to ensure residents benefit from an efficient administration. Residents are assured of a sound management of their financial interests. EVIDENCE: The manager continues to send out monthly newsletters to each resident. She attaches to this a questionnaire for each person to complete. The questionnaires cover such topics as: • Care • Catering and food • Daily living • Management • The premises Feedback was sought from families but none was evident from other healthcare professionals. As yet the information gained from these surveys had not been used to produce an annual development plan.
Park Manor D55 S4055 Park Manor V220982 240505 Stage 4.doc Version 1.20 Page 15 Feedback was sought from families but non was evident from other healthcare professionals. Residents confirmed that they either deal with their own finances or have appointed a responsible representative to do so. This is frequently another family member. The home does hold ‘pocket money’ for residents at their request. All monetary transactions were recorded and were seen to be up to date and accurate. Park Manor D55 S4055 Park Manor V220982 240505 Stage 4.doc Version 1.20 Page 16 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x
COMPLAINTS AND PROTECTION x x x x x x 3 x STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 1 x x 2 x 3 x x x Park Manor D55 S4055 Park Manor V220982 240505 Stage 4.doc Version 1.20 Page 17 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 OP18 Regulation 12(1) Requirement The homes policy relating to adult protection must inform the reader to consult with an officer of the local Dorset Social Care and Health agency in the event of an allegation of abuse and must refer him/her to the No Secrets guidance provided by that agency. Timescale for action 31/08/05 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. Refer to Standard OP1 OP33 Good Practice Recommendations The updated service user guide should be made available to all service users. Analysis of service user surveys should be used to assist in the creation of an annual development plan. Other stakeholders should also be consulted. Park Manor D55 S4055 Park Manor V220982 240505 Stage 4.doc Version 1.20 Page 18 Commission for Social Care Inspection Unit 4, New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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