Inspection on 11/04/08 for Parkcare Station Road

This inspection was carried out on 11th April 2008.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Parkcare Station Road 03/05/07

Parkcare Station Road 27/04/06

Parkcare Station Road 08/11/05

Parkcare Station Road 18/08/05

Parkcare Station Road 05/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Parkcare Station Road 8 & 8a Station Road London N21 3RB Lead Inspector Wendy Heal Key Unannounced Inspection 11th April 2008 10:30 Parkcare Station Road DS0000010591.V361307.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 Parkcare Station Road DS0000010591.V361307.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. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Parkcare Station Road Address 8 & 8a Station Road London N21 3RB 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) 020 8360 2274 020 8360 6565 station.road@craegmoor.co.uk Parkcare Homes (No2) Ltd Mrs Tunay Arslan Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users Limited to 15 adults of either gender with a learning disability (LD) not to exceed 12 accommodated at 8 Station Road, London N21 3RB and 3 accommodated at 8a Station Road, London N21 3RB. . Date of last inspection 3rd May 2007 Brief Description of the Service: 8 & 8a Station Road is managed by Craegmoor Healthcare Services. It is a service for young people with a learning disability. Station Road provides a service for 15 young people, both male and female, between the ages of 18 and 65 years. The people have a wide range of needs and require very variable levels of support. Some of the people require support in relation to their behavioural difficulties. Station Road is a large detached building located in Winchmore Hill. Eight people live in the main part of the home. Three people live in a separate flat with its own kitchen and lounge and are accessed by a separate staircase from the rear garden of the home. All of the people living in the home have a single bedroom. The bedrooms are located across three floors of the house. There is no lift in the home. Two of the bedrooms have their own en suite shower room but the rest access four shared bathrooms/shower rooms. On the ground floor there is a large lounge, dining room and kitchen. On the first floor there is a small, quiet sitting room. At the rear of the home there is an enclosed garden. The fees at the home range from six hundred pounds to thirteen hundred pounds approximately. The home has the purpose and function document and inspection report on their notice board for interested parties to view. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is (1 star) this means that people who use the service receive adequate outcomes. This was an unannounced inspection and took place as part of the inspection programme. Compliance was checked against key standards and took approximately 6 hours. I undertook a tour of the building spoke with the people who live in the home and members of the staff team. I gained further information from the Annual Quality Assessment form, by an inspection of the documentation kept in the home, including care plans and health and safety documentation. The manager offered her assistance throughout the period of the inspection. I would like to thank the people who use the service and the manager and staff for their openness and participation. What the service does well: What has improved since the last inspection? Care plans are now based on person centred planning and are being kept up to date which ensures that people’s individual needs can be met. Food products are regularly date checked, labelled and stored appropriately which safeguards people’s health and wellbeing. The bedroom ceiling in the flat, which, had fallen down, has now be repaired and the room is fit for use. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 6 A new kitchen has been fitted in the main house, which means the home is a nicer place for people to live. The bedroom that had electrical wires coming from the electrical equipment was effectively organised which ensures that any potential risk of injury are minimised to those people living and working in the home. A temporary deputy manager has been appointed at station Road whilst a professional qualification is completed. This will ensure that the manager is provided with the necessary professional support to manage the home. Clear fire records were available at this inspection within the home. This ensures that effective recording procedures are in place with regard to fire procedures. This benefits the health and wellbeing of the people living and working in the home. What they could do better: One identified person needs an up to date contract, which will ensure their individual rights are respected. Health care appointments are not effectively recorded and do not indicate the outcomes of the appointments. Health action plans do not have a date recorded on the document when the information is reviewed which does not safeguard people’s health and wellbeing. Weight charts are not being kept up to date. This does not ensure that an effective weight -monitoring programme is in place. The fire doors in the flat do not have magnetic door closures fitted. The doors are too heavy for the people living in the flat to operate effectively. This does not safeguard the health and wellbeing of people living in the home. A request has been made for the work to commence. The time scale for work to be agreed and acted upon under the current approval process needs to be more effective to prevent delays with regard with work that needs to be acted upon. The hall carpet is very dirty worn and needs to be replaced to ensure that people are living in a safe clean environment. The outside of the home needs to be painted as it is not very welcoming to those people who live or may wish to live there. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 7 The Deputy Manager position, which has been appointed to for a period of six months (by a member of staff within the organisation) must be advertised as soon as this position becomes vacant. This has been a requirement since the last two inspections. This is an essential factor with regard to the manager running the home in the most effective way. Staff must undertake training in relation to Manual Handling, fire safety CosHH and adult protection, which will ensure that staff have the necessary skills to meet people’s needs. The Supervision notes of the manager must be kept in an identified place within the home. Supervision must be provided at least six times per year. The supervision - sessions must provide the manager with the opportunity to discuss the needs of the people living in the home as well as the organisations business related issues. This was a recommendation at the previous inspection. 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. Parkcare Station Road DS0000010591.V361307.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 Parkcare Station Road DS0000010591.V361307.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): 1,2,5, People who use the service receive a good, outcome in this area. The judgement has been made using available evidence including a visit to the service. People who use the service are provided with the information they need to make an informed choice about whether the service is suitable for them and their needs. The service is good at assessing people’s individual aspirations and needs. Not all of the people living in the home have an individual contract of terms and conditions, which does not ensure people’s rights are respected. EVIDENCE: Since the previous inspection one new person has moved into the home. There is an up to date statement of purpose, which ensures that those people living in the home have clear information to enable them to decide if the home can meet their individual needs. There is a service user guide, which is in a pictorial form and is therefore accessible to all of those people who may wish to read it. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 10 The homes manager has completed Individual assessments to cover the individual aspects of this person’s specific needs. This ensures this person’s individual needs can be met. One identified person did not have an up to date contract of terms and conditions which means this persons rights are not fully protected. Parkcare Station Road DS0000010591.V361307.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): 6,7,9, People who use the service receive a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People’s care plans are being kept up to date which benefits their wellbeing. People make decisions about their lives, which empowers them. People are supported to take risks, which assists them to develop their independence. EVIDENCE: People’s care plans were inspected. They were clear to read. The care plans are now in a pictorial form, which means it is accessible to the people who need to use it. People’s care plans are based on person centred planning. The care plans inspected contained information such as life history, important people in my life, important dates, daily events, medication, personal care and social interaction. The care plans are signed by the person the care plan is about which makes them feel valued. The document focuses on the quality of care of the individual, which benefits people’s wellbeing. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 12 Care plans specify the areas in which people make decisions about their lives with assistance, for example one identified person discusses anxiety or concerns with staff and has a book were the information is logged and agreed action is noted which empowers this person. The risk assessments to show potential risks for individual people are being reviewed and kept up to date. This minimises the potential risks to the people living and working in the home. The risks include emotional health in terms of personal relationships, fire, which includes a disclaimer agreement and challenging behaviour. Parkcare Station Road DS0000010591.V361307.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): 12,13,15,16,17, People who use the service receive a good, outcome in this area. This judgement has been made using available evidence including a visit to this service. People are being supported to broaden the activities they participate in within the community. People are part of the community and are encouraged to take part in age peer and culturally appropriate activities. People are supported to choose healthy nutritious meals, which benefits their health and wellbeing. EVIDENCE: The people who live at Station Road attend day services ranging from one day a week to five days per week. A number of people travel independently and make good use of their freedom pass, which assists to further develop their self-esteem. The sessions that people attend at college include participation in art classes, cookery, shopping and trips out all of which improve people’s life skills and further enriches their lives. People who live at Station Road use the local pubs and shops, which promotes their social interaction within the community. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 14 A number of people also attend a social club on a Thursday evening, which provides them with the opportunity to meet other friends from outside their home, which makes them feel valued. One person attends church regularly on a Sunday, which promotes his spiritual wellbeing. On the day of the inspection a number of people were on their Easter break, some were watching television, listening to music, others were taking part in an art and craft session with the support of the deputy manager of the home. I witnessed a discussion taking place by the people living in the home and they decided that due to poor weather conditions they would not go for a picnic. They decided, after a long discussion that they wanted to buy lunch and come back and watch a film together. They left to shop for their food and choose to do this in a group or on their own which promotes their self esteem. People living in the home do have a key to their bedroom door, which they do use to lock their rooms when they go out, which ensures their privacy and personal space is respected. The contact arrangements for the people living at the home vary and range from personal visits to the family home. Visits from family members to the individuals own home. Some people receive telephone calls from family and friends. This assists their emotional wellbeing and makes them feel valued. The manager has agreed to record these visits and methods of contact more effectively as arrangements regarding contact were not always logged. The young people I spoke with confirmed that family contact was taking place. Staff were aware of people’s preferences in relation to their preferred meals. The menu of food available was wholesome and nutritious. On the day of the inspection the kitchen was not in use as a new kitchen was in the process of being fitted. However all of the people spoken with said “the food was good.” One person who is a vegetarian said, “I choose my own food and it is good.” I inspected the fridge freezer and fridge and food stored in the fridge was labelled properly and was in use by date, which ensures that people’s health and wellbeing is protected. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 15 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): 18,19,20, People who use the service receive an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. People receive personal support in a way they prefer and require, which ensures their individual rights and choices are respected. People’s physical and emotional health care needs are not being fully met due to ineffective recording. The process for administrating medication is effective and promotes the good health of people living in the home. EVIDENCE: The record of people’s health care appointments for each person was inspected. They indicated that people are being supported to receive their individual healthcare checks, which ensures their health is being monitored. However this information was not always effectively recorded on the health record but was identified on the daily recording sheet. This does not assist with the monitoring of people’s health care needs. A consistent process with regard to the recording of information is not being used. People’s health action plans need to be fully up-to date including the recorded date of when they were last reviewed. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 16 The record of people’s weight charts were not up-to-date which means their weight monitoring programme is not being effectively monitored which does not benefit their health and wellbeing. People’s preferences in relation to how their personal care is provided are highlighted in their individual care plans, which mean their personal wishes are being respected. The medication and administration records were inspected and all medication has been signed for on the Medication administration record, which supports good practice regarding people’s health. The medication cupboard was inspected and was found to be in order. This further safeguards people’s health. Peoples PRN guidelines are in place and have been signed by a professional person. This ensures that effective procedures are in place to safeguard people’s health. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 17 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): 22,23, People who use the service receive a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People who are living in the home can be confident that their views are listened to and acted upon since the recording and action taken in relation to complaints was found to be in order. Adult protection procedures were available which ensures staff have the information available to protect people living in the home from abuse neglect and self-harm. EVIDENCE: I looked at the complaints book at the time of the inspection. One new complaint had been made since the previous inspection, which had been appropriately responded to which ensures that complaints are taken seriously. The Adult Protection guidelines for the organisation were available along with those in relation to the relevant placing authority, which means that staff have the information available to them to protect people from potential abuse. One member of staff needs to undertake adult protection training to ensure that their knowledge and skills is being kept up-to-date. (Please see the section headed staffing). People’s financial records were inspected and found to be in order which means that effective recording systems are in place to protect people from financial abuse. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 18 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): 24,30, People who use the service receive an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. People are not living in a homely safe clean environment, which does not benefit their health and wellbeing. EVIDENCE: During the inspection I identified a number of environmental improvements. One bedroom in the flat has now had the ceiling that had cracked and fallen down repaired which ensures the room it fit for use. The identified person who had a number of wires coming from the electrical equipment in their bedroom has had the wires organised, to ensure that any potential risks of injury for the people living and working in the home are minimised. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 19 The kitchen is being updated with new kitchen cupboards and worktops. There is also a new cooker, extractor and new kitchen sink which, makes the home a better place to live in. There are new sofas in the lounge, which were present at the last inspection and brought by a donation of money made to the home. I was also informed at that time that this money was also going to be used to obtain a garden bench and new garden furniture, which as yet had not been obtained. The manager has informed me the furniture as been obtained and will be available for use this summer, which will improve the quality of life of the people living in the home. There are a number of further improvements that need to be made. The new fire doors in the flat are too heavy. It was expressed by people who use the service that the doors being difficult to open to access or exit the rooms when carrying objects such as a cup of tea it was identified that magnets door closures must be fitted to the fire doors. One person has said “I am becoming agitated and hitting the doors”. This situation is causing him some distress. This further impacts on the health and safety of the other people living in the home. The doors are being wedged open with paper which, impacts on the health and safety of everybody living and working in the home. I did receive a document from the manager, which confirms that a request for this work to be completed was requested in February 08. I was further told it was going through the approval process. I have contacted the manager who said the work has been agreed and the contractor was being contacted for a start date. The work has not yet been carried out. After the inspection having contacted the manager further I have been informed the work will commence on the 12/05/08. Due to the period of time that it has taken for work to be agreed and then completed and the fact that this action was completed after the inspection a requirement has been made. I have also been informed that a magnet closure is also going to be placed on the large gate to the side of the home to ensure this does not have to be opened with a key in the event of a fire- taking place. One the day of the inspection the first Aid box specifically Identified for use in the flat was in the office. The manager acted on my request on the day of the inspection to ensure this item was returned and available for use in the flat. I have therefore made no requirement in relation to this. The Hall carpet needs to be replaced because it is worn and dirty and poses a potential health and safety risk to the people living and working in the home. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 20 The manager has provided me with a document that confirms that a request was made for the carpet to be replaced in April 2008 and this request is going through the approval process. After the inspection I was informed the replacement of the carpet has been agreed. I would like to be provided with evidence of a start date when this work is due to take place. The bathroom on the top floor needs the bath panel replaced as it is chipped worn and not secure. The manager has confirmed speaking with her after the inspection this has been replaced. One particular person living in the home has requested that her bedroom is decorated. The manager has agreed to forward to me the proposed schedule which indicated the planned decoration of people’s bedrooms therefore a requirement has not been made in relation to this. The vacant bedroom needs to have all stored items removed this concern was identified in the area managers monitoring visit. The manager said she is in the process of ensuring the appropriate action is taken to make the room fit for use. The exterior walls of the home needs to be painted. The dirty appearance does not provide a good first impression to those who live or wish to live at the home. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 21 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): 32,34,35,36, People who use the service receive an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. Not all staff have undertaken training in the identified areas to ensure they can meet the needs of the people living in the home. People are protected by the homes recruitment policies and procedures. Not all staff are receiving supervision, which does not benefit the people living in the home, as a consistent approach by staff cannot be maintained. EVIDENCE: The service now has a deputy manager in post. This person has transferred from another home within the organisation and started working at the home the week of the inspection for a period of six – months whilst a professional qualification is undertaken. The need to appoint a deputy manager was a requirement made at the previous two inspections. I need to reiterate again that this post must be appointed to when the current deputy manager returns to her established position. Within the staff team there are some people who need to undertake training in relation to cosHH, manual handling, fire safety and one-person needs Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 22 training in relation to adult protection. This will ensure staff are qualified to meet peoples needs. The staff files were inspected and contained all of the criminal records bureau checks, staff references and the required staff identification records, which assist to protect people from potential abuse. Staff supervision records were inspected and staff members within the team are receiving regular supervision, from their manager. This ensures that a professional and consistent approach is undertaken by these staff and assists with the development of the people both living and working in the home. However at the time of the inspection the manager could not produce her supervision records for 2007 and could only provide me with one supervision record for 2008. The manager’s supervision must be fully recorded and must provide the opportunity to discuss the needs and concerns in relation to the people living in the home as well as the business arrangements. This document must be signed and dated by all parties to ensure that accurate recording is taking place. This will also ensure that the manager is receiving adequate support to the enable her to manage the home. I have raised this issue at previous inspections. I have received an email informing me that all supervision dates have been booked with the managers immediate line manager. I was asked take this into consideration when completing the report. Given the fact that this issue has been raised previously combined with the fact the supervision folder was not available a requirement has been made in relation to supervision. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 23 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): 37,39,42, People who use the service receive an adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. The home now has a deputy manager in post, which means the manager is supported to ensure the home is managed in the most effective way. People can be confident that their views underpin all self-monitoring review and development within the home. People’s health safety and welfare is not fully promoted and protected. EVIDENCE: The manager has completed the Registered Managers Award and has completed an advanced management qualification, which benefits the people Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 24 living in the home as it supports the manager in providing the necessary experience and knowledge to manage the home. The home now has a deputy manager in post. However this is for a period of six months whilst this person is undertaking a professional qualification whilst this ensures the manager has the necessary support to consistently manage the home this post must be advertised as soon as it is known the deputy manager is returning to her established role. One person said, when asked about staff, “the deputy is lovely and when asked what they liked about her they replied, “she is fun.” During a tour of the home I noticed that all fire doors were not closed in the flat, which, does not assist, to protect people who live in the home in the event of a fire taking –place. The fire drills fire alarm tests were found to be in order. Fire exits were clear and free from obstruction. All fire safety notices contained the relevant information. Emergency lighting checks were found to be in order. The fire doors in the flat are due to be fitted with magnetic closures to ensure people’s health and wellbeing is safeguarded. (Please see the section headed environment.) The electrical, gas and portable appliance testing certificate were found to be in order, which promotes people’s health and safety. The homes environmental health report, which applied to the kitchen area, was also inspected found to be in order. The manager will be completing a new quality assurance audit for this year and asking for feedback from the people who live in the home their relatives and relevant professionals. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 25 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 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 X X 3 X Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 26 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 YA5 Regulation 15 (1)(c) Timescale for action The Registered Manager must 01/06/08 ensure that the identified person has a new contract/terms and conditions, which are up-to-date, signed and dated to ensure the person’s rights are protected. The Registered Manager must 20/05/08 ensure that that health care appointments including the outcomes of appointments and health action plans are effectively recorded and have the date when they are reviewed. This will ensure that people’s health care needs are fully met. The Registered Manager must 15/05/08 ensure that people’s weight charts are kept up to date. This will ensure that an effective weight- monitoring programme is in place to safeguard people’s health and wellbeing. The Registered Manager must 16/05/08 provide documented evidence to the Commission For Social Care Inspection Confirming that the magnetic closures have been fitted to the doors in the flat. This will ensure that people’s DS0000010591.V361307.R01.S.doc Version 5.2 Page 27 Requirement 2. YA19 12 3. YA19 12 4. YA24 23 Parkcare Station Road 5. YA24 23 (2)(b) 6. YA35 23 7. YA36 18 (2) 8. YA37 18 (1) health and wellbeing is fully safeguarded. The Registered Manager must ensure that documented evidence confirming the start date when the hall carpet will be replaced is sent to the Commission For Social Care Office. This will ensure that the home is effectively maintained and ensure people are living in a pleasant safe hygienic environment. The Registered manager must ensure that the identified staff undertake training in health and safety, manual handling, CosHH and adult Protection. The provider must ensure that the manager receives supervision at least six times per year and the documents must be available for inspection. This will ensure that the manager is effectively managed and the needs of the people living in the home are met. The Registered Manager must ensure that the deputy manager post is advertised when the sixmonth period is up if the deputy manager returns to their established role. This will ensure that the home is effectively managed and the needs of the people living in the home are met. 12/05/08 01/07/08 20/05/08 01/10/08 Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 28 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 YA24 Good Practice Recommendations The Inspector strongly recommends that the exterior of the home is painted to ensure that the first impression of the home is of a clean well kept property. Parkcare Station Road DS0000010591.V361307.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Contact Team Caledonia House 223 Pentonville Road London N1 9NG 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 Parkcare Station Road DS0000010591.V361307.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. 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