Inspection on 17/05/05 for Park View

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 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 View 16/03/09

Park View 18/03/08

Park View 09/03/07

Park View 05/06/06

Park View 10/11/05

Park View 09/12/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Park View 100 - 104 County Road North Hull East Yorkshire HU5 4HL Lead Inspector Tina Bettison Unnnounced 17th May 2005 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 J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Park View Address 100 - 104 County Road North, Hull, HU5 4HL 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) 01482 448911 Kingston upon Hull City Council CRH 15 Category(ies) of LD 15 registration, with number of places Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9/12/04 Brief Description of the Service: Parkview is a purpose built establishment, comprising three bungalows each with five single ground floor bedrooms, a lounge/dining room, one bathroom and two separate toilets. The three bungalows share a large garden but each has its own patio area. Residential care is provided to a maximum of 15 service users who have a learning disability, and who may also be wheelchair users. The home is close to local shops and next to a small park, and approximately 5 or 6 miles from the city centre of Hull. The previous owners submitted a voluntary cancellation to their registration in August 2004 and since that time Hull City Council have been managing the home. Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 12 hours and was carried out because a number of concerns/ complaints had been received by the CSCI in relation to staffing numbers and skills and care practices. Jacqui Campbell Regulation Manager accompanied the lead inspector for part of the inspection. A tour of the premises took place and staff files and care records were examined. Rotas, medication records, staff lists and training records were examined. 5 of the staff, the manager and a relative were spoken to. Care practices and interactions were observed during the inspection. The Commission for Social Care Inspection is working with the local authority to improve standards in the home, however if improvements are not made within reasonable timescales the CSCI will consider taking enforcement action. What the service does well: What has improved since the last inspection? The statement of purpose has been updated and now meets the requirements, thereby giving new and existing service users, families and professionals a clear guide as to what the service provides. Decoration and furnishings are being gradually improved. All three kitchens have been refurbished; new laundry equipment has been purchased and fitted, thus working towards providing a safe and clean environment in which service users live. Some staff training has been provided and all staff has had CRB clearances undertaken, thereby raising the standard of care provided to service users and protecting them from harm. Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 6 Moving and assisting assessments have been undertaken for those service users requiring them, thereby promoting safe systems of working that protect service users and staff from harm. What they could do better: Service users plans must improve, Individual service user plans were available however they did not reflect the full range of needs of service users and did not ensure that all aspects of health, personal and social care needs are identified and planned for. Plans were basic, not up to date and had not been reviewed. The registered person must ensure that staff know what to do for each service user and specialist advice must be followed. Service users must be supported to make and attend health care appointments. Service users confidential information must be protected, so that service users privacy and dignity is respected and service users know that information about them is handled appropriately. Complaints must be looked into properly so that the person making the complaint feels that they have been listened to. Records examined did not evidence a thorough investigation of the issues raised with outcomes and there was no evidence of feedback to the complainant. Staffing is a major issue within the home, high use of agency staff, low numbers of permanent staff leads to poor care practices. Agency staff are not assisted to know what the needs of the service users are due to poor service user plans and lack of service specific training. Staffing must be provided in enough numbers and with the right skills to look after the service users and staff must be supervised to do the job properly. Staff must be provided with training and must be helped to work within Local authorities policies and procedures. A quality monitoring system must be introduced to make sure that everyone is consulted about the running of the home and continuous improvements are made. To make sure that the home is safe and comfortable for people living there redecoration must take place, the new fire alarm system must be fitted, and the dining tables must be replaced. Staff facilities must be provided and private meeting rooms created in which to hold meetings, supervision, etc. At the time of the inspection the home had a temporary manager, this does not give service users and staff a sense of stability. The recruitment and registration of a permanent manager and senior staff is essential to make sure the above areas are improved upon. Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 7 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 J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 8 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 J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 9 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 Service users are not provided with enough information regarding the home they are living in. EVIDENCE: The Local Authority has taken over the registration for the home on a temporary basis. A statement of purpose has been developed, and since the previous inspection has been updated to cover all areas detailed in Regulation 4 and Schedule 1. A service user guide has been developed for each bungalow and produced in a format that is accessible to service users, however this still requires further development to ensure it meets regulation 5 and NMS 1.2. There had been no new admissions to the home since the previous inspection therefore it was not possible to explore whether the information provided prior to admission was sufficient. . Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 10 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) 6,7,10 Service users do not have a service user plan that reflects their full range of needs, choices etc thereby placing them at risk. Without this there is no assurance that their care needs will be met. EVIDENCE: Individual service user plans are available however they do not reflect the full range of needs of service users and do not ensure that all aspects of health, personal and social care needs are identified and planned for. Plans are basic, are not up to date and had not been reviewed. This is compounded by the high use of agency staff that do not have the historical knowledge of service users needs and who rely on the quality of the service users plans in which to ascertain their needs. This was particularly evident for one service user who had had a speech and language therapy assessment with regard to difficulties he was having with feeding and swallowing. The required action to be taken by the staff had not been transferred to the individual service user plan and staff were observed to give him a cut up meal of chicken pie and chips when a liquidised/smooth, soft diet had been required by the speech and language therapist. There was Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 11 evidence in the food monitoring chart that this had been happening on a regular basis. Where service users display behaviours that can be difficult to manage and specific techniques or methods of communication are required in order to minimise the risks this was not found to be documented in the service user plan either in the form of a service user plan or behaviour management strategy. The inspector observed a situation escalating when a service user was expressing a wish for a specific item of clothing and some of the staff were not aware of this particular need. Due to the communication difficulties of the service user she was finding trouble expressing her wishes and was getting agitated and hitting out. When the item of clothing was located by another member of staff the service user quickly calmed down. Another service user was observed to be spending the majority of the day outside wandering the garden and was not allowed access to the other bungalows; any restriction of this nature must be clearly documented in his service user plan. Discussion with staff suggested that they were not involved in the preparation of service user plans, they were not all aware of service users particular needs and communication methods and were not made aware of changes needed to made following review or re assessments. They acknowledged that plans were well out of date and not reviewed regularly. Service user plans were not provided in a format that made them accessible to service users. Discussion with staff and the manager and observations confirmed that service users confidentiality was not being respected despite this being highlighted at the previous inspection. There are no rooms available for handover meetings, meetings with relatives, reviews, supervision etc leading to all discussions taking place in the communal lounges in front of other service users, visiting relatives, workmen etc. From discussions with the manager and staff it was evident that confidentiality remains a huge issue within the home. There is a policy and procedure that clearly defines confidentiality and when this should be breached. However staff spoken to appeared to be unaware of where policies and procedures are kept and there were no records to evidence that staff had received briefings, training or any supervision regarding this issue. Some staff members appear to breach confidentiality on a regular basis. Confidentiality remains a huge issue within the home all discussions, handovers, meetings, visitors conversations are all held in front of service users therefore they are aware that there information will not be handled appropriately. Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 12 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) EVIDENCE: None of these standards were assessed in full at this inspection however staff and relatives stated that service users are not able to go out into the community and engage in activities both social and educational due to the staffing problems within the home. Park View J54 Park View S62146 V228184 17 May 05 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) 18,19,20 Service users healthcare needs are not adequately catered for. Facilities are not available for the safe storage of controlled drugs; thereby there is a possibility of drugs being mishandled and service users not being able to receive their medication. EVIDENCE: Three service users care files were examined as part of the inspection process. One service user had had a speech and language assessment however the requirements made were not being followed, another service user had good evidence of contact with GP, orthodontic dept, chiropody and physiotherapy however this service users relative is heavily involved in all aspects of care. For the third care file examined there was little evidence that service users healthcare needs were adequately being addressed. There were minimal records to support that an annual health check had been completed and that access to dentist, optician, audiologist, chiropody, community nurses and therapists was being facilitated on a routine basis for all service users. Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 14 The home has policies and procedures for the administration of medication however there were no facilities for the storage of controlled medication should any of the service users be prescribed any, despite this being a requirement from the previous inspection. There are currently no service users self-medicating, although there are places in their rooms to lock medication away safely. There are written policies and procedures in place for staff to adhere to regarding administration of medication. Each bungalow has its own store for medicines and recording systems in use. These were on the whole found to be satisfactory, with the exception of records confirming that the medication was being appropriately received into the home. Staff spoken to confirmed that they had received some training for the administration of medication provided by the local authority. However this did not include a competency check or a workbook to complete at the end to ensure staff understand their responsibilities. There are some service users requiring specialist medication, which is only administered by district nurses or staff whom the district nurse has deemed competent and willing to do so. The home does not have a refrigerator for medication. Park View J54 Park View S62146 V228184 17 May 05 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 Complaints made to the manager of the home are not handled appropriately and relatives are not confident that their concerns will be listened to, taken seriously or acted upon. The staff team are not fully aware of the Protection of Vulnerable Adults policies and procedures and their responsibility within these therefore strategies are not in place to ensure that service users are protected from abuse, neglect and harm EVIDENCE: The home has a detailed formal complaints procedure provided by Hull City Council but the complaint record and anecdotal evidence indicates that complaints received by the manager of the home from relatives were being dealt with in an informal ad hoc way. Records examined did not evidence a thorough investigation of the issues raised with outcomes and there was no evidence of feedback to the complainant. The CSCI has received a number of comments and complaints about the running of the home, all of which have been addressed during the course of this inspection. From discussion with staff it was apparent that they were not fully informed about the Protection Of Vulnerable Adults Policies and Procedures and their responsibilities within this. There was no evidence to support that all staff had received any training or briefings. Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 16 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) 24,25,27,28,30 Improvements have been made to the home, however despite these improvements service users continue to live in a home whose appearance continues to be generally run down with holes in plasterwork, damaged doors and a cluttered, untidy environment. All Service users bedrooms were single and in close proximity to the bathrooms, they were suitable for their needs, pleasantly decorated and personalised. EVIDENCE: From observations and discussions with staff, management and relatives it was apparent that a significant amount of work was being undertaken to improve the home both in terms of its function and general appearance. New laundry equipment had been purchased and fitted, all three kitchens had been refurbished and agreements given for showers to be fitted in bathrooms and a new fire alarm system to be installed. All of which aims to provide service users with a safe and comfortable home in which to live in. Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 17 Despite this work the home still appears run down, there are holes in the plasterwork, damaged doors and on the day of inspection it was untidy and rooms were out of use due to kitchen items being stored. New dining tables had been purchased that were totally unsuitable for the environment, making it appear institutional and limiting the communal space for staff and service users to move around. This posed a health and safety hazard. There were no private areas for visitors and /or meetings consultations etc. All Service users bedrooms were single and in close proximity to the bathrooms, they were suitable for their needs, pleasantly decorated and personalised. There was evidence of TV’s, stereos, photographs etc. Bathrooms were observed to be institutional, stark and uninviting. The specialised baths were quite old and service users toiletries were stored in baskets in the bathrooms. Equipment was available to maximise service users independence and serviced appropriately. Park View J54 Park View S62146 V228184 17 May 05 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) 31,32,33,34,35,35 Staffing in the home is of major concern. There is a high use of agency staff, poor rota management, no supervision taking place, lack of training both mandatory and service specific and all of this leads to service users needs not being adequately met. EVIDENCE: From discussions with staff, examinations of staff files, rotas, training records and observations it was evident that there are significant problems with the staff team in the home. Staff spoken to did not appear to aware of the Hull City Councils policies and procedures and had not received training or briefings in key areas and thereby do not promote the aims of the home. Staff had not received a copy of the General social care Council code of practice and was not aware of its content and the high use of agency staff meant that the staff were not aware of service users particular needs. There were very low numbers of staff with NVQ level 2 and there appeared to be little progress being made to register staff for the qualification although most spoken to expressed a wish to undertake this. Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 19 From observations some staff appeared to be disinterested in the service users and spoke mainly to each other, they did not have the appropriate communication skills to interact with service users and were not all aware of how to deal with particular behaviours. During the inspection inspectors observed staff sitting around openly discussing issues in front of service users and not interacting with service users. This was confirmed by a visiting relative who stated, “ staff just sit around, there is no stimulation, and service users don’t go out, there are no activities provided”. It was also reported that because staff move around the bungalows this leads to a lack of stability and continuity for service users. Staffing levels are poor there is a high use of agency staff, high turnover of staff and lack of leadership, due to there not being a competent senior care worker on each shift. The manager confirmed that she was in the process of implementing a new rota for the senior staff that would ensure a senior worker on each shift. This must be implemented as soon as possible. It was reported that the care staff rota is not an equitable rolling rota and that staff find it difficult to plan their home life and maintain a home/work balance. This needs to be addressed. Communication in the home is poor, few staff meetings and staff reported lack of effective handovers. Training provided since the previous inspection included basic food hygiene, moving and assisting, basic first aid, infection control, fire awareness and medication awareness however despite this not all staff were up to date with mandatory training. Staff training remains poor with both records and discussion with staff confirming that little training was being provided either mandatory or service specific. The manager did not have a training plan for the home. The manager and some staff reported a racist culture in the home, which must be addressed, staff had not received any training on equal opportunities, disability equality training and race equality and anti racism training. Staff were not receiving any formal supervision and had not had an annual training and development assessment and profile. Staff files evidenced that robust recruitment was in place; all files examined contained a current CRB clearance and schedule 2 information. Park View J54 Park View S62146 V228184 17 May 05 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) 37,39,40, 42,43 With a temporary manager and minimal support from senior care workers, there is ineffective leadership, guidance and direction to staff to ensure that service users receive consistent quality care. This results in some practices that do not promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The current manager has been seconded to the home from Hull City Council on a temporary basis; she is not currently registered with the CSCI. The local authority needs to ensure that a registered manager is in place to provide a consistent, stable platform in which the home can improve. The manager has completed NVQ 4 in Management and is currently undertaking the Registered Manager’s Award covering the appropriate care components. She has 15 years previous experience in a managerial and caring role. Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 21 The Local authority has a quality assurance system however this has not yet been fully implemented within the home, this means that service users and their families views are not utilised to help shape the way the service is provided in the future. Staff spoken to appeared to be unaware of where policies and procedures are kept and there were no records to evidence that staff had received briefings, training or any supervision regarding implementation of Hull City Councils policies and procedures. Training provided since the previous inspection included basic food hygiene, moving and assisting, basic first aid, infection control, fire awareness and medication awareness however despite this not all staff were up to date with mandatory training. Staff training remains poor with both records and discussion with staff confirming that little training was being provided either mandatory or service specific. The manager did not have a training plan for the home. The manager confirmed to the inspector that all records relating to service users were now stored securely and in accordance with the data protection act. As part of the inspection the maintenance records were examined and all were in order, however the inspector was concerned that the intumescent seals on the fire doors appeared to have gaps and must be attended to. The manager confirmed that a new fire alarm system was due to be fitted soon. The home appears run down, there are holes in the plasterwork, damaged doors and on the day of inspection it was untidy and rooms were out of use due to kitchen items being stored. New dining tables had been purchased that were totally unsuitable for the environment, making it appear institutional and limiting the communal space for staff and service users to move around. This posed a health and safety hazard. Park View J54 Park View S62146 V228184 17 May 05 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 2 x x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x x 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 2 x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score 1 1 1 3 2 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Park View Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 1 x 1 2 x 2 2 J54 Park View S62146 V228184 17 May 05 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 1 Regulation 5 Requirement The registered provider must provide a service user guide that sets out clear and accessible information covering all aspects of standard 1.2. The Registered person must ensure that the service users plans reflect the full range of needs and detail what support staff need to provide to meet service users needs, plans must be reviewed at least 6 monthly. The registered person must ensure that service users plans cover situations where service users present behaviours that pose a risk to themselves and/or others The registered person must ensure that service user plans are provided in an accessible format to service users The registered person must ensure that staff receive appropriate support and training with regard to the service users’ needs. Any restrictions must be clearly documented identifying the risk to the service user (Timescale of 9/3/05 not met). The registered person must Timescale for action 31/8/05 2. 6 15 30/9/05 3. 6 12, 13 (4c) 31/8/05 4. 6 15 30/9/05 5. 6 12,13,17 and 18 31/8/05 6. 10 12,17 30/6/05 Page 24 Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 7. 17 and 6 15,16 (2i) and 13 (1b) 12,18 8. 18 9. 19 13 (1) 10. 20 13(2) 11. 20 13(2) 12. 22 22 13. 24 23 ensure that the confidentiality policy and procedure is implemented within the home and that adequate provision is made for meeting rooms to enable handovers, reviews etc to be held in private (Timescale of 9/3/05 not met). The registered person must ensure that specialist advice with regard to eating and drinking is adhered to and that this is explicit in the service users plan The registered person must ensure that staff develop and maintain appropriate relationships with service users and treat them with respect and dignity at all times (Timescale of 9/3/05 not met). The registered person must ensure that service users have access to healthcare provision and a minimum of an annual health check is completed The registered person must ensure that the medication records are maintained accurately, also that regular monitoring of medication stock takes place. The registered person must provide Controlled Drugs cabinets that meet the requirements of the Misuse of Drugs Act 1971 The registered person must ensure that all issues raised by service users and/or their families are recorded and a record of any investigation, action taken and outcome. The registered person must ensure that the home is redecorated both inside and out and that a planned maintenance programmed is providedt 30/9/05 from the date of inspection 31/8/05 30/9/05 31/8/05 from the date of inspection 31/8/05 Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 25 14. 31 18 (4) 15. 16. 32 33 18(1a) 18(1a) 17. 35 18(1c) 18. 35 18(1c) 19. 35 18 (1c) 20. 36 18(2) 21. 37 8 22. 39 24 The registered person must ensure that all staff are aware of their own role and the roles of others and that they are issued with the GSCC code of conduct, understand it and work within it,s guidelines The registered person must ensure that 50 of staff are qualified to NVQ level 2 The registered person must ensure that staffing levels are maintained as directed and the use of agency/casual staff is kept to a minimum, each shift having permanent members of staff on duty (Timescale of 9/3/05 not met). The registered person must develop and implement a training programme which meets the Sector Skills Council workforce training targets.(Timescale of 9/3/05 not met) The registered person must ensure that staff receieve training in equal opportunities, disability equality, race equality and anti racism training. The registered person must ensure that all staff has an individual training and development assessment and profile The registered person must ensure that all staff receive supervision a minimum of 6 times a year The registered person must ensure that a registered manager is in place to provide a consistent, stable platform in which the home can improve The registered person must ensure the home’s quality assurance system is developed, and includes consultation with 31/8/05 30/6/06 30/6/05 30/9/05 30/9/05 30/9/05 30/6/06 30/6/05 31/10/05 Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 26 23. 40 24 24. 25. 42 43 18 8 26. 42 and 24 23 27. 42 and 28 23 28. 42 and 28 23(3) 29. 23 13(6) 30. 42 4(a) stakeholders, that information it produces is collated and a written report is produced and that it is sent to the CSCI and given to the service users. (Timescale of 9/3/05 not met)) The registered person must ensure that all staff have access to, understand and apply all policies and procedures and codes of practice The registered person must ensure that all staff are up to date with all mandatory training The registered person must ensure that systems are put in place to ensure that the overall management of the service is effective The registered person must ensure that the home is kept tidy and that matters of routine decoarating and general maintanance are attended to The registered person must ensure that the large dining tables are replaced with smaller ones to ensure the safe movement around the home od staff and service users The registered person must ensure that facilities for staff are made available in which they can store personal items and to take adequate rest time away from service users. The registered person must ensure that all staff are made aware of their resonsibilities in relation to the POVA policies and procedures The registered person must take advice from the fire officer with regard to ill fitting intumescent seals on the fire doors . 31/8/05 30/9/05 30/6/05 30/9/05 31/10/05 30/6/05 30/9/05 from the date of inspection. Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 27 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 33 Good Practice Recommendations It is recommended that the new rota for the senior staff is implemented as soon as possible and that senior staff are on duty on all shifts, due to the ongoing problems currently experienced within the home. An application for the registration of a manager is to be submitted to CSCI 2. 37 Park View J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 J54 Park View S62146 V228184 17 May 05 Stage 4.doc Version 1.30 Page 29 - 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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