Inspection on 10/06/05 for Park View

This inspection was carried out on 10th June 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 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 View 18/11/08

Park View 26/06/06

Park View 15/11/05

Park View 23/11/04

Park View 12/07/04

Park View 18/02/04

Park View 18/11/03

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

CARE HOME ADULTS 18-65 Park View 9 - 11 Park Avenue Mitcham Surrey CR4 2EQ Lead Inspector Liz OReilly Unannounced 10 June 2005 10:00 am 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Park View Address 9 - 11 Park Avenue Mitcham Surrey CR4 2EQ 0208 646 2467 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) Mr Feeroz Hosanee Mr Feeroz Hosanee CRH - Care Home 6 Category(ies) of MD - Mental Disorder (6) registration, with number MD (E) - Mental Disorder over 65 (6) of places Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2004 Brief Description of the Service: Park View is a registered care home for up to six service users with mental health needs. The home is situated in a residential area of Mitcham, close to local shops and transport services. Park View is made up of two residential properties which have been joined together. The property is owned by Mr Hosanee who also owns a second home in this area. Park View is not identifiable as a care home. The aims and objectives of the home have been set out in the Service User’s Guide and Statement of Purpose copies of these documents are available in the home. Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one regulation inspector on 10th June 2005. During the course of this visit the inspector had the opportunity to speak with three residents, one member of staff and the Registered Person. What the service does well: What has improved since the last inspection? What they could do better: The care planning system in place needs to be improved to ensure that clear objectives in relation to the needs and wishes of individual residents are included. The systems in place for informing relatives and placing authorities of any incident involving a resident need to be reviewed to ensure that the relevant people are informed without delay. The systems in place for recording individual residents finances must be improved. Staff training must be reviewed to ensure that all staff are provided with on going training on caring for people with mental health needs. Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 6 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 View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 2 Written information on the home is available which can assist residents in making an informed choice of where to live. The manager of the home has not ensured that the needs and aspirations of residents have been fully assessed prior to admission to the home. The lack of information in the form of an up to date Care Management assessment does not ensure that the full needs and wishes of residents can be met by the home. EVIDENCE: The home has produced a service user guide and a statement of purpose which sets information on the home for residents. Since the last inspection two new residents have moved into the home. The documentation for one of these residents was examined. The home were seen to have carried out their own assessment of needs. However the information available from the placing authority prior to admission appeared to refer to the residents activities and aims in a previous home. In order to ensure that the home can meet the full up to date needs and wishes of residents the Registered Person must ensure that prior to admission to the home they are supplied with a copy of the care management assessment. Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 7 Further work needs to be carried out on individual care plans to ensure these include the personal goals of residents. Information supplied by residents indicated that they are supported to make decisions about their lives. However this must be reflected in the individual care plan and recording to ensure all staff are aware of decisions made by individuals and provide consistent support. EVIDENCE: Care has been taken to include the rights, independence, comfort, privacy, social and daily living skills within the individual care plans. However further work needs to be focused on including clear, measurable aims, objectives and timescales for individuals. To ensure residents have a clear understanding of any arrangements made on their behalf care plans must include details of any agreement in place for supporting individual residents in relation to their finances to include the reasons for such support. Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 10 Care plans were seen to be reviewed on a regular basis and signed by individual residents which indicates some consultation on the care planning process. Further work needs to be carried out in relation to the daily recording in the home. It was clear that the daily records were made by one member of staff. In other instances the daily record did not reflect that activities of individuals as reported by staff. The daily record must provide a clear, accurate record of individual activity to ensure that the needs and wishes of residents are being met. The record should be made by those staff present and who were directly involved in the care provided. Consideration should be given to involving and or consulting individual residents in this recording Residents spoken to at the time of this visit stated that they were free to make their own decisions about their day to day lives and activities. Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 17 Residents are involved in the local community and activities according to their individual wishes. Further work needs to be carried out to ensure that the activities offered to residents meet their individual needs and wishes. EVIDENCE: Residents stated they enjoyed joining in activities in the home but they were free to choose not to join in. One resident stated they enjoyed helping out in the home by carrying out “some cleaning jobs.” One resident stated they liked to go to another home in the street for the occasional meal. In order to ensure that the individual needs and wishes of residents are fully met in relation to activities within the home and in the local community further work needs to be carried out to provide individualised care plans . Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 12 Residents stated that staff supplied them with information on the local community activities and services during their first few weeks at the home. Staff provide advice and support for residents on accessing local services and facilities. Residents were seen to have access to the whole of the home and were seen to come and go from the home as they wished which indicated their right of freedom of movement was respected. At the time of the last inspection of this home a requirement was made for a snack to be provided in the evening to ensure that the gap between the last meal of the day and breakfast is not excessive. This information has not been added to the menu. In order to ensure that all residents are provided with sufficient food throughout the day the Registered Person must ensure that a snack is provided and that this is included on the menu for the home. In order to ensure that the preparation and serving of food respects the residents cultural and religious requirements a review of the menu must be carried out in consultation with individual residents. One resident spoken to gave very positive comments on the food provided. One resident stated that the “staff are good cooks.” Another resident stated they “really enjoy the food especially the fish and chips on Fridays.” Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 & 21 The health care needs of residents are met. The health and welfare of residents is protected by well managed medication procedures. Minor amendments need to be agreed with the pharmacist to ensure the labelling of medication is clear. The systems in place for informing interested parties following the death of a resident in the home needs to be reviewed. EVIDENCE: All residents are registered with local GP practices and residents continue to have visits from community psychiatric nurses where necessary. Records are maintained within the home in relation to last eye tests, sight tests and medical appointments to ensure residents have access to regular health care checks. A record of the weight of each resident is maintained on a monthly basis which assists staff in monitoring individual health. At the time of this visit none of the residents in the home were self medicating. The health and welfare of residents was seen to be protected by medication being stored safely and up to date records maintained. The manager and one carer have completed accredited training on the management of medication. Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 14 It was noted that labels supplied by the pharmacist were not accurate in all instances. To ensure that there is no danger of errors staff must ensure that the labels are checked on all medication received into the home. It was also noted that staff were not supplied with a description of the medication supplied. The Registered Person should ensure that a description of all medication administered is made available to staff. Following the death of a service user in the home there were delays in contacting family members and the placing authority. To ensure that the family, friends and other professionals are informed as soon as possible of the death of a resident the procedure in place must be reviewed and all staff must be made familiar with the procedure. The Registered Person must make checks with residents, their families and the placing authority to ensure they have an up to date record of who should be informed of any death or accident to a resident. Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 A complaints system is in place to ensure the views and concerns of residents are listened to and acted upon. The procedures in place for the management of residents finances are not sufficient to protect residents. EVIDENCE: The home has in place policies and procedures for dealing with complaints. A comments book is available at the entrance to the home in which any resident or visitor to the home can use to raise concerns or make comments. At the time of this visit no complaint had been received by the home since the last inspection. Two complaints have been received by the Commission in relation to this home. One complaint was investigated and found to be not substantiated. During the course of the investigation into the second complaint it was noted that the record of money held in the home on behalf of one resident had not been adequately maintained. The record was not accurate. In order to safeguard the finances of individual residents the Registered Person must ensure that up to date accurate records of any money held in the home are maintained. Since this investigation the Registered Person informed the inspector that he was holding money for only one resident. The records for this resident were examined and found to be in good order. The Registered Person stated he would be changing the systems in place for the recording of money held to introduce additional checking at each transaction. Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 16 To ensure that residents are safeguarded from abuse the Registered Person has attended training on the protection of vulnerable adults and following this has provided in house training for the other staff in the home. Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 Residents are provided with a homely environment which is clean and hygienic. EVIDENCE: The three residents spoken to at this visit all said they were very comfortable in the home and were happy with their own bedrooms. The main lounge for the home is furnished with domestic style furniture. In order to ensure the home continues to be well maintained a programme for the redecoration and or refurbishment of the premises, with timescales, should be compiled with a copy of the programme supplied to the Commission. The Registered Person should make plans for the refurbishment of the kitchen area and the redecoration of the bathrooms. Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 & 35 Sufficient staff were seen to be on duty to meet the needs of the present resident group. Further work needs to be carried out to ensure that residents are supported by staff with appropriate knowledge and training to meet their needs. EVIDENCE: At the time of the last inspection of this home only one member of staff who was under the age of 21 was found to be on duty. A requirement was made for a minimum of two staff to be on duty during the day at all times. At the time of this visit the Registered Person and two other members of staff were available in the home. At night one member of staff sleeps on the premises. The Registered Person keeps a record of any instance where the person sleeping in the home has been called out to ensure that this arrangement continues to meet the needs of the residents in the home. No resident has required assistance at night. The Registered Person must ensure that staff are provided with on going training on caring for people with mental health needs. One member of staff has completed NVQ level two in care and has commenced a distance learning course in infection control. Another member of staff is in Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 19 the process of completing a health and social care course at a further education college. In order to ensure that residents are cared for by an adequately trained and knowledgeable staff group the Registered Person must ensure that a training and development plan is produced for each member of staff which sets out the training completed and the training needs of each person. Evidence of a minimum of five paid days training per year must be available for each member of staff. Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 Work has commenced on a system for residents views to be sought to ensure these are incorporated in any review or development plan for the home. Checks are carried out on the building and equipment to ensure the health and safety of residents, staff and visitors to the home. EVIDENCE: The Registered Person has carried out surveys with residents to seek their views on the home. These surveys covered a wide range of issues including the general service, complaints, the food and accommodation provided and individual rights and interests. To ensure the views of residents influence the development of the home, this year a new system has been devised to review the whole service taking into account the views of residents, visitors and other professionals who have contact with the home. Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 21 Once completed a copy of the report compiled following consultation must be provided to the Commission and the outcomes of residents surveys must be made available to the residents in the home and to any prospective residents. Checks are carried out on the building and equipment to ensure the health and safety of residents, staff and visitors to the home. Records evidenced weekly checks on the fire alarm system and the hot water temperatures are checked every two weeks. Risk assessments are in place for the use of any chemicals or cleaning solutions. Monthly maintenance and health and safety checks are carried out on the premises. Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x 3 2 x x 2 Standard No 31 32 33 34 35 36 Score x 2 2 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Park View Score x 3 3 2 Standard No 37 38 39 40 41 42 43 Score x x 2 x x x 3 G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 23 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 2 Regulation 14(1) Requirement The registered persons must ensure that prior to any admission to the home a care management assessment is obtained. The registered persons must carry out a review of the care plans in place to ensure:Care plans reflect the individual needs and wishes of resident. Care plans set out clear objectives and timescales for actions. The registered persons must ensure that any arrangements in relation to supporting residents to manager their finances is included in the care plan. The registered persons must ensure that the daily record maintained in the home is accurate. The daily recording must be completed by the staff on duty at the time. The registered persons must ensure that a snack is provided to all residents in the evening between the last main meal of Timescale for action 1st August 2005 2. 6 15(1) 12(3) 1st September 2005 3. 6 15(1) 1st August 2005 4. 6 17(1) 1st August 2005 5. 17 16(2)(i) 12(4) 1st August 2005 Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 24 the day and breakfast. (timescale of 21.02.05 not met) A review of the menu must be carried out in consultation with residents to ensure that cultural and or religious needs of individuals are met. The registered persons must carry out a review of the procedures in place in relation to a contacting relevant people following the death of a resident to ensure that all concerned are informed without delay. The registered persons must ensure that up to date and accurate records are maintained for any money held on behalf of a resident. The registered persons must ensure that all staff receive regular on going training on the care of people with mental health needs. The registered persons must ensure that all care staff are provided with a training and development plan which includes evidence of at least five paid days training each year. (timescales of 01.11.04 and 21.02.05 not met) The registered persons must ensure that the contact details for the next of kin or representative of each resident are up to date and accurate. The registered persons must supply to the Commission a budget statement for the home. (timescales of 01.11.04 and 21.02.05 not met) 6. 21 12(4) 1st August 2005 7. 23 17(2) Schedule 4 (9) 18(1) 1st August 2005 8. 32 1st September 2005 1st September 2005 9. 35 18(1) 10. 21 17(2) Schedule 3 (3)(b) 25 1st August 2005 11. 43 1st August 2005 Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 25 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 20 Good Practice Recommendations The registered persons should ensure that all medication labels are checked when delivered from the pharmacy. Consultation should take place with the pharmacist to ensure that a description of all medication is available to staff. The registered persons should compile a programme for the redecoration and or refurbishment of the premesis, a copy of which should be supplied to the Commission. The registered persons should make plans for the refurbishment of the kitchen area and the redecoration of the bathrooms in the home. 2. 3. 24 24 Park View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ground Floor - CSCI 41-47 Hartfield Road Wimbledon SW19 3RG 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 View G54-G04 S27247 Parkview V234120 100605 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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