Inspection on 03/05/07 for Park Way

This inspection was carried out on 3rd May 2007.

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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Park Way 09/08/05

Park Way 12/04/05

Park Way 09/11/04

Park Way 08/06/04

Park Way 20/01/04

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

CARE HOME ADULTS 18-65 Park Way 76 Alexandra Road Farnborough Hampshire GU14 6DD Lead Inspector Ian Craig Unannounced Inspection 3rd May 2007 09:55 Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 1 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 Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 2 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 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 Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park Way Address 76 Alexandra Road Farnborough Hampshire GU14 6DD 01252 547782 Telephone number Fax number Email address Provider Web 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 Lawrence Alexander Mrs Diane Alexander Miss Lisa Carolyn Mitchell Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users are not to be admitted under the age of 18 years Date of last inspection 9th August 2005 Brief Description of the Service: Park Way provides care for up to thirteen male and female adults, aged 18 to 65 years, within the mental disorder category. Mr and Mrs Alexander own the home and Miss Lisa Mitchell is the registered manager and is supported by a deputy manager. Mr And Mrs Alexander own the Park Group of services that consist of Park View, Park Way and Park Avenue homes and an Outreach service. The home is located in Farnborough within easy access to local shops and other amenities. The home is on a main bus route. The building is a three-storey domestic detached house, comprising of seven single and three double bedrooms. One of the single rooms provides an independent flat facility on the second floor. The homes communal space comprises of two lounges and separate dining room, a small conservatory and a further conservatory that provides a smoking facility. There is a garden, which includes seating for residents and visitors. The home’s fees range from £398.28 to £674.70 per week. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection consisted of a tour of the premises, examination of records, documents, policies and procedures. Discussions took place with 2 staff and with one of the owners, Mrs. D Alexander. One member of staff was interviewed. Several residents were spoken to and one person was interviewed. Residents were also observed using the home’s facilities. Four survey forms were returned to the Commission, which had been completed by individuals. What the service does well: There are many examples of the home’s residents being able to exercise choice in how they spend their time as well as being able to participate in the organisation of activities. Residents’ privacy and dignity are also promoted. Evidence was available to show that residents are fully involved in their care planning. Assessments and care plans are generally of a good standard with the exception for one person. These show how mental health needs are being addressed and how improvements in the mental health of individuals has been achieved. Prospective residents are given information about the home before moving in and trial visits can be arranged so that the person can see if the home meets their needs. The home carries out assessments of those referred for possible admission, and actively seeks information about the person’s needs from the relevant mental health services. This includes liaison and attendance at mental health service planning meetings. There are opportunities for residents to take up a variety of activities both within and outside the home. These include work, holidays, leisure trips, shopping and developing independent living skills such as cooking. The home aims to help residents in developing and maintaining independent living skills with a view to moving on to less supportive accommodation. Residents reported that the service meets their needs, that staff are supportive, and that they are satisfied with the service provided. The home is comfortable and generally well maintained with a few areas needing attention. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 6 Records of any monies held on behalf of residents are well maintained. Residents are not charged when transported by staff in the home’s vehicle. Sufficient numbers of staff are provided to meet the needs of the residents. Recruitment checks are carried out on newly appointed staff, although it was noted that one person had commenced work prior to a criminal record bureau check being obtained. Staff receive support in the form of supervision and training. The home has a training programme. The home has a quality audit system, which involves obtaining the views of staff, residents, involved professionals and residents’ relatives regarding the service provided by the home. What has improved since the last inspection? What they could do better: Clearer details are needed in care plans regarding action that staff should take when dealing with identified risks. It was identified that maintenance of certain records has lapsed which had previously helped with the monitoring of health needs, ensuring residents are offered a key to their room and that each person has an adequate diet. The home needs to ensure that each new staff member has had a criminal record bureau check or a protection of vulnerable adults ‘first’ check before commencing work in the home. Greater attention is needed to ensuring residents are protected from possible burns from radiators and from possible scalds by hot water in showers and baths. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 7 The home’s manager wrote to the Commission following outlining how the requirements made as a result of this inspection will be implemented. Reference is made to this in the relevant sections of the report. 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. The summary of this inspection report can be made available in other formats on request. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Park Way DS0000012057.V336115.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that there are systems in place whereby residents have a full picture of the facilities and service provided so that they can make an informed choice whether or not to move into the home. Potential residents’ needs are fully assessed ensuring that the home accommodates those whose needs can be met. EVIDENCE: Residents confirmed that they are given a copy of the home’s Guide. This was also recorded in each person’s records. This gives details of the service provided, including reference to the Commission inspection reports being available, the complaints procedure, the staffing structure and house rules. Residents also confirmed that they are able to visit the home and that this helped them to decide if they wished to move in. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 10 Records show that the home carries out its own assessment of the needs of anyone referred for possible admission on a pro forma entitled, Pre Placement Assessment. These are comprehensive and include details of mental health needs as well as an assessment of independent living skills. The assessments are signed and dated by the person completing them. In addition to this, the home obtains information from the referring mental health services. Copies of multi agency planning meetings are held with the person’s records and show that a representative from the home attends these meetings. Each person has a contract, which they have signed. These include details of the weekly fee at the time of admission. The contract could be improved by the inclusion of the arrangements and financing for the main meals. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst each person has a care plan specifying in some detail how needs are to be met, it was unclear how staff should deal with identified risks. This has the potential to place staff and residents at risk. Residents are able to make their own decisions and participate in various aspects of daily life at the home. EVIDENCE: Assessments and care plans were examined for 4 residents. These are comprehensive in detail covering identified risks, mental health needs, how mental health needs are to be met, independent living skills, personal care, specific support with cooking, money management, controlling anger and one Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 12 to one sessions with a keyworker. Assessments use a rating code and are focussed on the individual needs and wishes of the person. Residents sign their care plans, and in one case the resident has been entering her own records in the contact sheets with the support of a staff member both of whom record a signature. This is an example of good practice. Risk assessments are completed and include details about mental health, including symptoms, signs of an increase in symptoms and any other relevant behaviours. It was noted that for one person, however, that there is a lack of guidance regarding the management of identified risks. Staff were asked about this and were not clear what to do. For the same person, there was also a lack of clarity in the plan whether or not the person could go out safely on his own. The manager has written to the Commission following the inspection to state that a risk assessment is now in place and that staff have been made aware of this. Records, feedback from residents, observation and discussions with staff all show that residents are involved in daily domestic routines in the home, that they can participate in house meetings, have a choice about what they want to do and that each person’s daily life reflects their own wishes and needs. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home enables residents to develop their independent living skills so that they can move to more independent accommodation. Residents take part in activities that reflect their preferences and needs. The home is not able to demonstrate that residents have an adequate diet. EVIDENCE: There is clear evidence from records, returned feedback forms, and discussions with staff and residents, that residents are able to maintain and develop independent living skills, as well as having opportunities for social, educational Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 14 and occupational activities of their choice. A resident described how he is encouraged to take responsibility for domestic tasks in the home; records supported this. One person has a job at a nearby shop. A resident attends a local gym. Residents are able to access local facilities. A care plan referred to a resident having a holiday accompanied by staff and the home’s management confirmed that this is offered to each person. Conversations with residents and records showed that residents maintain contact with family and friends and that use is made of the ‘payphone’ for keeping in touch. It was also confirmed from records and from residents themselves that they are able to attend local clubs for activities and socialising. Residents spoke of their individual right to make choices about how they spend their time. The home has its own vehicle, which is used to transport residents. There is no charge for this service. Whilst there is evidence that each person has opportunities for attending social, educational and occupational activities, the written assessments could be improved to show that each of these needs is being individually assessed and planned for. The manager wrote to the home following the inspection to state that a review form will be used to evidence that keyworkers support their clients to focus on their leisure and occupational needs Residents are admitted to the home on the understanding that they already have independent living skills so that they can shop and prepare food with staff assistance based on their assessed ability. Prior to admission, each person’s independent living skills are assessed and recorded. Records show that each person is assisted or supported with shopping and cooking according to their individual needs. Hence, the arrangements for each person are a reflection of their abilities. Each person is given £21.00 to purchase food for a midday and evening meal for seven days. There was a discussion with the staff and one of the owners about the amount of money given for food and the fact that this has not been increased for several years. This amount is reduced by £4.00 for one person when he/she goes away for the weekend. Mrs. Alexander indicated that these amounts and arrangements could be reviewed. Whilst the arrangement is included in the home’s Guide, the actual amounts are not included in either the Guide or the contract. Following the inspection the manager wrote to the Commission stating that a comparison with other services regarding the weekly food allowance will be taking place and that residents do not have to supply breakfast foods, fruit, bread, milk coffee, tea, butter, biscuits, juices and condiments. Examination of the food records, which are maintained for each person, had numerous omissions. For one person there was no record available for a whole week and for another person only two meals were recorded, when the amount spent was relatively low. The inspector highlighted that whilst the arrangement Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 15 for residents being able to develop cooking skills on an individual basis is commendable, that it was essential to maintain records so that the home can demonstrate that each person is receiving a varied and nutritious diet. It needs to be stated that the home also provides numerous food staples such as bread, tea, coffee, rice, salt and so forth. None of the feedback from residents criticised the quality or quantity of the food. It was also noted that there were ample supplies of fresh fruit in 3 fruit bowls on the dining tables. Care plans and daily records show the level of support and assistance that each person needs to prepare a meal. Records also show that the home monitors the weight of each person. Following the inspection the manager of the home wrote to the Commission stating that a more rigorous system is now in place to ensure that all food consumed by residents is recorded and that the home supports residents to have nutritious and healthy diet. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst there is evidence of residents’ personal and health care needs being addressed although the recording and monitoring of this needs to be improved. EVIDENCE: Resident’s records detail the level of support and assistance with personal care. Where relevant, advice and support is provided with sexual health. The home has a monitoring system for recording appointments for checks and treatment with the following: optician, dentist, hearing and chiropodist. It was noted that these had not been completed at all since 2004 for one person, that the sheet was blank for another person and that only an eyesight test had been arranged for another person. This form does not include reference to Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 17 annual health checks with each person’s general practitioner, which the home’s management stated is carried out and a record kept in the daily running records. Following the inspection the manager wrote to the Commission stating that any appointments will be recorded. Residents’ records showed that there is liaison with community mental services, including staff from the home attending Care Programme Approach reviews. Information is available on resident’s filed including copies of occupational therapy reports and reviews with psychiatric professionals. There was evidence in the records of one person’s improving mental health. The inspector observed staff dispensing medication to a resident. The resident was observed taking the medication and the staff member entered a signature in the medication recording sheets. Staff receive training in medication procedures as well as an annual assessment. This was confirmed from staff training records and from discussions with staff and the home’s management. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents’ views are listened to, sufficient safeguards are not taken to protect residents and staff from possible harm. EVIDENCE: Residents commented that their views are listened to and that they are able to make contributions to decisions about how the home is run. The home has a complaints procedure, which is included in the Guide supplied to each person. Residents commented that they know what to do if they have a complaint. The home has a copy of an adult protection procedure and staff receive training in this. Training is provided in dealing with ‘challenging’ behaviour although a care plan did not give guidance on how staff should respond to an identified and significant risk. The recruitment procedures for one recently appointed staff member did not include a criminal record bureau or protection of vulnerable adults check being completed before the person commenced work. This was a requirement the last time this was inspected. Procedures for the handling of residents’ finances were examined. Appropriate records are kept of any transactions, which includes any amounts deposited or withdrawn including a corresponding balance. The staff member and resident Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 19 involved in this sign a record each time a transaction takes place. At each staff shift ‘handover’ the amounts being held are checked and recorded by 2 staff. The inspector checked the amount held for one resident, which matched the record. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, homely and comfortable environment. EVIDENCE: The home is generally well maintained although some areas are showing signs of wear and tear. The home has a maintenance plan for redecoration. The two first floor bathrooms have been refurbished to a good standard. A ground floor bathroom has two missing tiles which the inspector was informed are to be repaired. Three bedrooms have an en suite toilet with a wash hand basin and one bedroom has an en suite shower with a toilet. Several bedrooms were seen and these are decorated to a good standard with the exception of damaged carpet in one room. Personal belongings are evident Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 21 in bedrooms showing that residents are able to personalise their rooms. Residents are able to have a lock to their bedroom door. However, one resident stated that he had not been offered this facility. The home uses a recording system to show that each person has been offered a key, but this has lapsed. The management agreed to ensure that this is revisited and that each person is offered a key to their room. Lockable storage space is not provided in every bedroom and this was thought to be the result of furniture being replaced. This needs to be addressed. The manager wrote to the Commission following the inspection stating that these matters are being addressed. The home has 3 double bedrooms although only one room is currently occupied by 2 people. The inspector was informed that it is the home’s intention for all bedrooms to be single in the future. Residents were observed using the lounge facilities where they watched the television. Several residents were also seated in the garden or were using the designated smoking area in a conservatory. Vases of fresh flowers are placed on each of the 3 dining tables and in several other places in the home. There are picture displays in the hall of photograph collections of residents enjoying activities. The home was found to be clean and staff are trained in infection control. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 22 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents benefit from adequate numbers of trained staff, the staff recruitment procedures do not protect residents. EVIDENCE: The home aims to provide at least 2 staff from 7.30am to 9pm Monday to Friday, and at weekends one staff member from 9am to 11am and 2 staff from 11am to 8pm. At other times there is one staff on duty. Night time staffing consists of one ‘waking’ staff member The staff rota and observation on the day of the inspection confirmed this. Residents confirmed that the staff are helpful and that they have one to one sessions with their keyworker. A staff training programme for 2007 was displayed in the office. Individual training records were maintained for each staff member showing training in the following: adult protection, first aid, food hygiene, fire safety, health and Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 23 safety, medication, managing challenging behaviour, supervising staff, NVQ 3 and risk assessments. A training course in mental health has been started which all staff will have access to. A training matrix is maintained so that the home’s management can monitor that staff are completing the necessary training. Records show that staff have a performance review as well as a skills assessment, and that identified training needs are met. For example, one person’s training need was identified as attending a Care Programme Approach review. Records had been maintained to show that supervision takes place, which was also verified by staff. Newly appointed staff have an induction programme and a staff induction feedback form confirmed that the induction takes place. Staff described the management as supportive. Recruitment procedures were examined for 3 recently appointed staff. These showed that appropriate checks had been carried out, including identity details, 2 written references, a health questionnaire and a criminal record bureau (CRB) check. There was no record of a protection of vulnerable adults (POVA) check being carried out although the inspector was assured by the response from the home’s management that a full enhanced CRB is completed. It was noted that one person commenced work in the home prior to a CRB or POVA ‘first’ being obtained. This was discussed with the management who stated that it was their understanding that this was permissible so long as the person was ‘shadowed.’ Advice was given on checking the CSCI web site on staff recruitment. A requirement was previously made for the home to ensure that new staff have a satisfactory check against the POVA list before commencing work. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 24 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run to reflect the needs and wishes of the residents, although improvements are needed in several areas. EVIDENCE: The manager has attained the Registered Manager’s Award and has completed several other relevant courses such as the NVQ Assessors, Train the Trainer and Enabling Teaching in the Workplace. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 25 The home uses a Quality Management System, which is completed each year. This involves the completion a Quality Control questionnaire, which is given to residents, relatives of residents, staff and involved professionals. The inspector was informed that the home arranged for an advocate/representative to help the residents complete the CSCI resident survey form. The home’s management described the aim of involving residents more in the running and decision making in the home. Staff safety has already been referred to in the complaints and Protection section. Staff described agreed procedures for dealing with any aggression by residents. Service certificates and the fire log book showed that the fire safety equipment was being serviced and tested in accordance with fire safety regulations. Procedures for ensuring that residents are protected from hot water and hot surfaces were examined. Checks are made, and a record made regarding hot water, but it is unclear what is being checked as only a tick is entered with no indication of whether or not this includes a temperature check. The management were unsure what the check involved. No radiator covers have been installed. The home’s management stated that a risk assessment had been carried and recorded but it could not be found on the day of the visit. Following the inspection the manager wrote to the inspector to state that these assessments were being reviewed. The inspector was informed that restrictors have been installed to prevent possible falls from first floor windows. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 26 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 Standard No Score 1 3 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 27 No 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 YA9 Regulation 13 Requirement Care plans must set out procedures and guidelines for staff to follow for minimising any risks with identified mental health needs and for activities such as going out alone. These should be agreed with the relevant community mental health services. The home must be able to demonstrate that residents have a nutritious diet by maintaining records of food provided. The home must ensure that all new staff have a satisfactory check against the Protection of Vulnerable Adults (POVA) list prior to commencing work. This is outstanding from the report of 12/04/05. The damaged carpet in a resident’s first floor bedroom must be repaired or replaced. The home must ensure that residents are protected from DS0000012057.V336115.R01.S.doc Timescale for action 03/06/07 2 YA17 16 Schedule 4 19) Schedule 2 30/06/07 3 YA34 03/06/07 4 YA26 16 30/07/07 5 YA42 13 03/06/07 Park Way Version 5.2 Page 28 possible scalding by hot water by carrying out appropriate checks. The home must ensure that residents are protected from possible burns from hot surfaces such as radiators by carrying out and recording risk assessments. 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 YA5 Good Practice Recommendations Details of the arrangements and amounts for weekly food provision for each person should be included in the contract. Park Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Way DS0000012057.V336115.R01.S.doc Version 5.2 Page 30 - 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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