Inspection on 17/05/05 for Park Mount

This inspection was carried out on 17th May 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Park Mount 10/05/07

Park Mount 01/12/05

Park Mount 19/01/05

Park Mount 18/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Park Mount 52 Park Mount Drive Macclesfield Cheshire SK11 8NT Lead Inspector Helena Dennett Unannounced 17 May 2005 at 9.30 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 Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Park Mount Address 52 Park Mount Drive Macclesfield Cheshire SK11 8NT 01625 616459 01625 616459 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) The Pallottine Missionary Sisters Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 This home is registered for a maximum of 30 service users in the category of OP (old age not falling within any other category) requiring personal care only. 2 The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 19th January 2005 Brief Description of the Service: Park Mout is a purpose built home set in two and a half acres of mature grounds. There is accommodation for thirty service user in single en-suite rooms on two floors. There is a lift on the first floor. Meals are taken in small goups of seven or eight,in the four dining rooms. There is a kettle and fridge in each dining room where residents and their visitors can make a drink andhave a snack. The kitchen facilities provided conform to the standards laid down by the Environmental Health Department. A chapel is situated within the home where all denominations are made welcome. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 0900hrs on 17 May 2005 and lasted five hours. The inspector spoke with nine residents, one relative, the manager and two members of staff throughout the day. Their comments are incorporated throughout the report. What the service does well: What has improved since the last inspection? Progress has been made on care plans. The manager confirmed that this work progressing and improvements will continue to be made. Liquid soap is now available in all communal toilet areas which improves hygiene and reduces the risk of cross infection. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 6 A representative of the organisation that runs the home has provided a report on the way the home is run to the CSCI. 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. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 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 Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 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) 3 Detailed assessments are carried out before people move into the home so that when they move in, there is information to show that their needs can be met at the home. EVIDENCE: Residents who had moved into the home recently confirmed that a member of staff came to speak with them before they could move in. Assessments completed before they moved in were available in residents’ files. These had all the relevant information about the individual to make sure that staff at the home were aware of their needs and that they could provide good care for them. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 9 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) 7,8,9 Care plans now contain more detailed information on the resident and how their needs should be met, so that staff have clear guidance on the care needed. Progress has been made on the management of medicines but further improvements must be made as these shortfalls have a potential to place residents at risk. EVIDENCE: Residents said that they were confident that their health care needs are been met by staff at the home. They confirmed that a GP visits when needed and that they can have the district nurse as necessary. One resident who has recently moved into the home was asked whether she felt her needs are met by staff at the home and said ‘I wouldn’t stay here if they weren’t met or if it wasn’t a good home’. Plans of care are in place for each resident and progress has been made on developing these since the last inspection. Staff are now updating plans as residents’ needs change. The manager confirmed that she is in the process of updating care plans as she gets to know the residents but that this will take time. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 10 There were records to indicate that the district nurses visit as needed. Staff gather information on what a resident eats and drinks during the assessment process. However, a formal nutritional screening on admission is not done, as was recommended at the last inspection. This would provide staff with information to identify whether a resident is at risk of not being nutritionally compromised which would affect their long term health care. See Recommendation 1. The management of medicines has been a concern over the last two inspections and requirements have been made to improve this. There was evidence that staff made attempts to meet the previous requirement and the storage of medicines has much improved. An additional medicine trolley has been purchased to assist with the process. However this was stored in the upstairs office, which was unlocked and the medicine keys were not kept securely, which is of concern. The manager took the keys during the inspection to make sure that they were stored securely and confirmed that they would be stored securely at all times. A new medicine policy is now in place. Staff are now recording the number of tablets received from the pharmacy and the totals on the medicine administration record (MAR) sheets. As pre-printed labels are not provided on the MAR sheets, staff have to transcribe the instructions for administering the medicines on to the MAR sheets. This has a potential to place residents at risk. For example, on one resident’s MAR sheet, the handwritten instructions stated ferrous sulphate 200mg two daily. This was identified on the MAR sheet as being administered one twice a day and this was signed as given as such. However the instructions on the box indicated that the intention was to take two tablets daily. The manager said she would contact the GP to clarify the instructions. Another resident is prescribed Warfarin tablets. The dosage is changed dependent on her blood results and doctor’s instructions. A separate book is kept with the up to date instructions for administering this medicine. Staff were signing the MAR sheet to confirm they had administered the Warfarin tablets. However, the MAR sheet identified the dose as 1mg and staff had not identified where they had administered 2mg in accordance with the instructions in the book. There was a note on one resident’s file that staff had borrowed a tablet from this person’s supply for another resident. This is poor practice which must cease. Other problems found with recording on the MAR sheets were omitted signatures and codes being used with no explanation of what they meant. See Requirement 1. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 11 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) 12,13,14,15 There are enough activities provided to meet the needs of residents who can also go out and about in the local community when they wish. Meals provided are nutritious and balanced to provide a healthy diet for residents. EVIDENCE: Residents were seen to be relaxed and comfortable, doing as they wished. One resident helping set the table for lunch said that he likes to help the staff. Another resident was helping to sew a hem on a dressing gown; others were sitting outside, in the lounge or in their own rooms, reading newspapers or watching television. Residents keep up their links in the community whenever possible. Trips out are organised. One resident organises regular slide shows and talks on various subjects. There was a relaxed atmosphere between the staff and residents; staff knew the residents well, were aware of their needs and showed respect. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 12 Mass is held in the home’s chapel every day for residents who wish to go. This is a very positive aspect of the home particularly for those residents who are Catholic. One resident who is not said that he felt this was a positive aspect of the home and whilst he does not attend Mass he didn’t feel that anyone would consider it compulsory for residents to go as many residents have other faiths which are supported by the staff. One resident has recently changed his faith and there was evidence in the care plans that staff were researching aspects of this new faith to make sure that they could assist this resident in following his beliefs. All of the residents were very complimentary about the food provided at the home. One resident said ‘it is like the food my mother used to make’. Another resident confirmed that at least three vegetables are provided at every meal. Residents said that they could make themselves tea or coffee in the small kitchenette and help themselves to snacks from the cupboard if they wanted to. A relative confirmed this. A bowl of fresh fruit was available in every lounge. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 13 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 There is a complaints procedure that provides information so residents and relatives know how to make a complaint. There is a protection of vulnerable adult procedure and a whistle blowing policy in place which ensure that the people living in the home are protected form abuse. EVIDENCE: Residents who spoke with the inspector stated they would approach the senior carer or the manager if they had a complaint. They stated that they had no complaints and that they were satisfied with the care provided. An adult protection and whistle blowing policy is in place and is accessible to all members of staff. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 14 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) 19,20,23,24,26. Residents live in a safe, comfortable home surrounded by well cared for gardens that they said they enjoy using in warm weather. They have been able to personalise their rooms with pictures and items of their own furniture to make them feel more homely. EVIDENCE: Residents said they were happy with their environment. Several of the bedrooms had been made more homely with many of the residents’ personal items, including their own furniture and photographs. Each room had an ensuite facility. There are small lounge/dining areas which residents were using. The home was found to be clean, pleasant and hygienic. Residents said their laundry was well cared for. The laundry was not visited on this inspection. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 15 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) 27,30 There were sufficient staff on duty to meet the needs of the residents. Staff have had sufficient training to be competent to do their jobs. EVIDENCE: Residents confirmed that there were sufficient staff on duty to meet their needs. They said they were satisfied with the staff and felt safe. Staff appeared relaxed in their approach and residents were not rushed. All members of staff are encouraged to develop their knowledge and skills through a training programme. A programme is in place to make sure that most of the staff have an NVQ Level 2 or equivalent qualification. Induction training is provided for all new members of staff to make sure that they have the skills necessary to provide good care for residents. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 16 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 &38 The manager is new in post and residents and staff confirmed they felt confident to approach her. The home is well run, with well trained staff and effective health and safety systems to ensure that residents and staff are safe. EVIDENCE: The manager is new to the home, although she has many years of experience managing a care home with personal care. She has previously been registered with the National Care Standards Commission and an application for registration has been submitted to the Commission for Social Care Inspection. This is being processed. Residents at the home said they felt the manager and staff are approachable. Residents meetings don’t take place at the moment; however the manager discussed the possibility of holding these. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 17 A programme of staff supervision is in place. The health welfare and safety of residents is maintained. Checks of recorded accidents are undertaken regularly to establish whether there are any trends and to put in measures to ensure the safety of the residents. A representative of the organisation that runs the home has submitted a report to CSCI done on a visit to the home undertaken under regulation 26 of the Care Homes Regulations to ensure that senior members of the organisation are aware of how the home is running. Reports will be made and sent to CSCI monthly. Fire safety training is conducted regularly, with weekly fire drills and training sessions on a Saturday for all staff. Moving and handling training is provided for all staff. All accident/incidents are recorded. Risk assessments have been done on all aspects of the building and an action plan is in place to address any issues. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 18 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x 3 x 3 Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 19 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. 2. Standard 9 9 Regulation 13 13 Requirement Medicines must be stored securely at all times. Medicines must be administered correctly in accordance with the prescription and records of administration be kept up to date and accurate. (This is outstanding from the last two inspections Timescale 19/2/05 not complid with) Timescale for action at all times at all times 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 8 Good Practice Recommendations Nutritonal assessments should be completed for all residents on admission to the home. Park Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Unit D, off Rudheath Way Gadbrook Park Northwich Cheshire CW9 7LT 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 Mount F51 F01 S6626 Park Mount V227214 170505 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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