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Inspection on 18/08/05 for Parkcare Station Road

Also see our care home review for Parkcare Station Road for more information

This inspection was carried out on 18th August 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

It was evident that the service adequately meets the needs of service users in relation to a range of appropriate activities including those within the local community. Also, the home caters well for individual dietary preferences.

What has improved since the last inspection?

The home has now met a number of requirements that had previously been restated as follows. The staff had undertaken training in a number of important areas such as epilepsy, first aid, medication and abuse. Maintenance requests had been met along with improvements in facilities provided such as updating of the shower room and the decoration of the hallway. A quality assurance survey had been completed. There was evidence of annual review meetings organised with the care managers.

What the care home could do better:

Persons in control of the home must have access and awareness of relevant information to ensure an appropriate service to service users. Regular updating and review of care plans and risk assessments to show staff and service user involvement is required, and these must be made available to service users. The frequency and standard of recording in relation to service user meetings must be improved. All incidents must be recorded with risk assessments updated to minimise future risk. Medication records must be amended to show the current provider. The complaints procedure must be improved and implemented. A number of maintenance tasks including repair of banisters, a kitchen tile, the vent in the laundry room, a bath panel, and kitchen cupboards, a door and exterior rendering must be addressed. The cause of damp in the identified bathroom must be investigated and addressed and the bathroom in the flat must be updated with a shower fitted. The staff rota must be accurate, a pest control agency must be contracted and feedback from the quality assurance review must be acted upon. Immediate requirements were made regarding the boiler, a defective fridge/freezer, fire procedures and a broken glass panel in the stairwell of the entrance to the flat. The organisation needs to meet timescales for taking action.

CARE HOME ADULTS 18-65 Parkcare Homes Ltd - Station Road 8 & 8a Station Road Winchmore Hill London N21 3RB Lead Inspector Wendy Heal Unannounced 18 August 2005 @ 09.45am 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. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Parkcare Homes Ltd - Station Road Address 8 & 8a Station Road, Winchmore Hill, London N21 3RB 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) 01992 309318 Michael Byrne for Parkcare Homes Ltd Tunay Arslan PC Care Home 15 beds Category(ies) of LD Learning Disability registration, with number of places Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 2. One specified service user who is over 65 years of age may remain accommodated in the home. 3. The home must advise the regulating authority at such times as the specified service user vacates the home. Date of last inspection 16 September 2004 Brief Description of the Service: Station Road is managed by Craegmoor Healthcare Services. It is a service for younger adults with a learning disability. Station Road provides a service for 15 younger adults, both male and female, between the ages of 18 and 65. The service users have a wide range of needs and require very variable levels of support. Some of the service users require support in relation to their behavioural difficulties. Station Road is a large detached building located in Winchmore Hill. Eight service users live in the main part of the home. Three service users live in a separate flat with its own kitchen and lounge and accessed by a separate staircase from the rear garden of the home. All service users 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 bathroom/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. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of the inspection the registered manager was on holiday and the deputy manager was not in post. A senior support worker was off sick. The unannounced inspection took approximately nine hours with the assistance of a manager from another Craegmoor home and in his absence, with the assistance of a senior staff member. Although the manager and senior staff were helpful, it was evident that they did not have access and awareness of some of the requested information. The service user guide was not available and a staff member’s file was not accessible because the manager did not have the key for the filing cabinet. There were eleven service users accommodated and four vacancies at the time of the inspection. The inspection included discussion with six service users, and three staff. Further information was obtained by a tour of the premises, the pre-inspection questionnaire and a range of documentation kept in the home. Eleven surveys were returned. The inspector wishes to thank the manager, staff and service users for their co-operation during this inspection. What the service does well: What has improved since the last inspection? The home has now met a number of requirements that had previously been restated as follows. The staff had undertaken training in a number of important areas such as epilepsy, first aid, medication and abuse. Maintenance requests had been met along with improvements in facilities provided such as updating of the shower room and the decoration of the Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 6 hallway. A quality assurance survey had been completed. There was evidence of annual review meetings organised with the care managers. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not inspected at the time of the inspection. EVIDENCE: These standards were not inspected at the time of the inspection. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 8, 9 The process to show that service users are actively involved in the participation and decision making in the home, and the information to show how they are supported to take risks to develop independence, is not adequate. Service users involvement is not fully reflected in their individual care plans. EVIDENCE: Service user care plans were inspected, they were generally clear to read but not regularly kept up to date. The format of the care plan does not show all identified needs. The desired outcomes and staff guidelines are mostly identified but there is no evidence to show that staff are using the plans to guide individual care or that they have had involvement. The care plans are not being reviewed on a regular basis and have not been signed by the service users or their representatives. There are risk assessments to show potential risks for some service users such as smoking and travelling outside the home however, they do not show clear evidence of being reviewed regularly. Requirements have been made in relation to the above. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 10 There was evidence of two service user meetings to discuss issues regarding the home and other issues of interest for the service users but they were infrequent and need to be more consistent to be effective. A requirement has been made in relation to this. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 15, 16, 17 Service users enjoy a range of appropriate activities including those within the local community. Contact with relatives is maintained and encouraged according to service users wishes. Service users rights are respected and they enjoy a varied and healthy diet. EVIDENCE: Service users attend day services ranging from one day per week to five days per week. A number of service users travel independently. On the day of the inspection six service users spoke with the inspector, both on a one to one basis and in groups. Several discussed both their day care arrangements, saying, “they were good”. One service user discussed her family contact due to take place at the weekend. Service users contact varies ranging from personal visits to telephone calls. The service users informed the inspector they enjoyed attending college and day care. One service user undertakes paid employment. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 12 The service users use local pubs and shops and on the day of the inspection were going to a barbecue in the evening. One service user discussed his recent 40th birthday. He showed the inspector presents received and pointed out the balloons in his bedroom from the celebration of his birthday. Staff interacted appropriately with service users. There was a notice on a service user’s bedroom door to ensure staff and service users are aware the service user is able to choose when to be alone or in the company of others. The inspector witnessed that on the day of the inspection those service users who expressed the wish not to attend the barbecue had their wishes respected. Service users spoke with the inspector about their recent holiday to Butlins and their wish to go to Centre Parcs next year and showed the inspector the brochure. Staff are aware of service users preferences in relation to meals and negotiated with service users in relation to their menu and diet. The kitchen was clean and tidy with food stored appropriately and within their sell by date. On the day of the inspection a senior member of staff was shopping independently for the home’s groceries and returned to assist the inspector. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 Staff were observed to have a good knowledge of service users’ needs, however care plans and other documentation are not kept up to date or reviewed. Staff did not have the necessary documented information to fully meet service users’ needs. EVIDENCE: There was information recorded relating to a sensitive incident involving a service user, which needed further monitoring, however, no information was available on how this was being monitored. Recording systems were said to be in place but not available to staff on duty or to the inspector. A requirement has been made in relation to this. Service user care plans were inspected. They were generally clear but not up to date. The format of the care plans does not show all identified assessed needs or aspirations. The desired outcomes of the assessed needs and staff guidelines as of how to achieve the outcomes are mostly identified but there is no evidence that staff were using the plans to guide individual care. The care plans are not being reviewed on a monthly basis and are not seen to be informed by a range of multi-disciplinary reviews and up to date risk assessments signed by all relevant parties. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 14 There is evidence that service users were supported to access external health professionals. On the day of the inspection two service users were attending medical appointments and these were recorded in the home’s diary. The medication for the service users was inspected with the relevant administration records and were found to be satisfactory. However, the dispensing pharmacist has yet to amend the name of the care home from the previous provider. A requirement is made in relation to this. There is satisfactory storage of medication with due regard to the appropriate storage required. All service users were mobile at the time of the inspection. Some service users were observed receiving prompting in relation to their personal care. One service user was seen receiving direct assistance with washing his hair. Staff interacted with service users in a respectful manner. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 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 The complaints procedure in place was inadequate. The home’s policy on adult protection needs implementing and monitoring to ensure the protection of service users. EVIDENCE: The complaints record book was inspected. Complaints had been received since the last inspection. The documentation did not show consistently the action taken by the responsible person. Action had not been recorded in relation to each entry made. The records did not show the date on which action was taken and was not always signed and dated. Improvements are needed in the layout of the complaints recording book so that there is recorded evidence of action taken by the responsible person, which is recorded in relation to each entry. The records need to show the date on which action was taken and must be signed and dated. A requirement is made in relation to this. Surveys returned from families confirmed that they did not receive copies of the complaints procedure. The staff had received training in relation to the protection of vulnerable adults, together with an introduction to protection issues. However, on the day of the inspection an entry in the message book recorded that an incident had taken place in relation to a service user. This had not been reported to the manager and an incident report had not been completed. Alterations need to be made in relation to the service users risk assessments and care plans. A requirement is made in relation to this. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 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, 26, 27, 28, 30 Service users have benefited from recent improvements in their environment. However, further maintenance is required to ensure the environment is homely, comfortable and safe. EVIDENCE: The home offers an appropriate domestic type environment. Service users benefit from plenty of lounge space, so they can choose which area to sit in. The shower room had been retiled and ventilation had been improved since the last inspection. There is evidence of recent decoration of the hallway. All but one of the service users bedrooms was inspected and was satisfactory. A tour of the building showed a reasonable standard of cleanliness. The inspector noticed several outstanding maintenance tasks that need to be rectified i.e. securing the spindles to the banister in the main house, replacing a cracked tile in the kitchen in line with current type, repairing of the vent in the laundry room, replacement of the bath panel in the bathroom in the main house (identified to senior member of staff on duty), replacement of door Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 17 handle on identified service users wardrobe and light bulbs to be fitted in service users bedside lamp. One en suite bathroom in the main house (which has had the shower removed) has a damp area behind the WC on the back wall, which needs investigation, repair and decoration. The cooker in the main house needs the knob replaced to allow all cooker plates to function. Requirements are made in relation to all of the above. Flat: The inspector observed the following outstanding maintenance requirements: handles need to be put on the kitchen cupboards, the door of the bathroom needs to be replaced, the door to the boiler in the flat needs repair, exterior rendering to the flat in relation to the area around the door which is cracking and needs to be investigated and repaired. The bathroom needs to be updated and a shower to be fitted. Requirements have been made in relation to all of the above. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 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) 33, 34, 35 Service users cannot be confident that their needs will be met by sufficient numbers of staff on duty. Staff had received a range of training and recruited appropriately. EVIDENCE: On the day of the inspection there was insufficient numbers of staff to meet service user needs when compared to the identified number on the staff rota. The staff rota displayed in the office was seen and was found to be inadequate. The staff rota did not show the staff members’ full names and the position they held. The shift times were not clearly identified - am and pm are not acceptable. As there is no manager or deputy manager on site currently the on call manager also needs to be clearly identified on the staff rota - this was not evidenced at the time of the inspection. The responsible person must ensure there is sufficient overlap of staff to cover busy times of the day such as late evening when medication is being administered and early morning when service users are getting up. One domestic staff is employed but her hours of work are not identified. There is no identified domestic support at the weekend. A requirement has been made in relation to the above. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 19 Staff were not fully aware of and did not have access to all information and systems within the home. The inspector checked two staff files including the CRB records of two staff, they were found to be satisfactory. The files were inspected at random and contained documentation to evidence the recruitment process. The inspector observed written evidence of recent ongoing staff training, which was confirmed by staff during discussions with them. Since the last inspection training had been undertaken in epilepsy awareness, manual handling, information on dealing with abuse and first aid training. The inspector was also informed that in July 2005 staff had undertaken training in autism, Makaton and protection of vulnerable adults. The person responsible for the cover arrangements at the time of the inspection has agreed to forward evidence of these training certificates to the Commission on receipt. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 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) 38, 39, 42 Service users cannot be confident in the management approach of the home. Service users views are formally sought but their views have yet to contribute to the overall development of services. Parkcare Homes have failed to make sure that service users at Station Road are living in a safe environment. EVIDENCE: Though the manager from another home and senior staff member were helpful, it was evident they were not fully aware of the systems in the home. Since the previous inspection the home had developed a Service User Quality Assurance Questionnaire. This gives service users and their families the opportunity to feed back formally their views on a range of areas regarding the quality of the service received. Meetings with service users are held but the manager must make sure the minutes are clear, concise and comprehensive. The responsible person must ensure that both the questionnaires and meetings are used to inform the Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 21 development plan if service user views are to contribute to the functioning of the home. A requirement has been made in relation to this. A range of health and safety documentation was inspected and found to be in order. These included an up to date fire risk assessment by UK Fire, records of fire drills and fire point testing. A current certificate of employees liability insurance was displayed. The water storage system had been professionally inspected to minimise the danger of Legionella. Health and Safety measures in the home were found to be inadequate and the following needs urgent attention: The boiler needs to be brought into line with current standards regarding ventilation and placement of the flue terminal as per gas safety check performed on the 9th March 2005 (an immediate requirement was made in relation to this). All fire safety notices to contain relevant information (an immediate requirement was made in relation to this). All door closures to be effective. All recommendations outlined by UK Fire in their latest fire risk assessment need to be implemented (an immediate requirement was made in relation to this). The London Fire and Emergency Planning Authority to be consulted about fire safety arrangements in the home and their advice acted upon (an immediate requirement was made in relation to this). Unused filing cabinet blocking passageway of the flat entrance must be removed. Requirements have been made in relation to all of the above. Other areas needing attention include: Glass panelling situated in the stairwell of the entrance to the independence living flat is cracked and must be replaced (an immediate requirement was made in relation to this). The fridge/freezer is defective and must be replaced (an immediate requirement was made in relation to this). A reputable pest control agency must inspect the premises regularly in the light of reported sightings of rats and the latest environmental inspection report. Requirements have been made in relation to all of the above. Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 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 x 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 x 2 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score 2 x 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Parkcare Homes Ltd - Station Road Score x 2 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 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 6 Regulation 15(2)b Timescale for action The registered manager and care 18/10/05 provider must ensure that the care plans are reviewed on a regular basis. The registered manager and care 18/10/05 provider must ensure that the care plans are made available to the service users to be signed by themselves or their representatives. The registered manager and 18/10/05 provider must ensure that risk assessments are reviewed. The registered manager and 1/10/05 provider must ensure that regular service user meetings take place that are clearly minuted. The registered manager and care 8/10/05 provider must ensure that the identified service user involved in an incident has their care plan and risk assessment updated and the incident reports are regularly completed. The registered manager and care 8/10/05 provider must ensure the dispensing pharmacist amends the name of the care home to show the current provider in relation to medication received. Version 1.40 Page 24 Requirement 2. 6 15(2)a 3. 4. 9 38 14 (2)a 24 (3) 5. 9 & 11 14.2, 13.4(3) 6. 20 13 (2) Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc 7. 22 22 (4) 8. 38 12 a 9. 24 23 (2)b 10. 24 23 (2)b 11. 24 23 (2) b 12. 24 23 (2) b 13. 24 23 (2) b 14. 24 23 (2) b 15. 24 23 (2) b The registered manager and care provider must ensure that when a complaint is made, that the complainant is informed and action is taken within 28 days. The complaint should be recorded in the complaints book, signed and dated. Persons in control of the home must have access and awareness of relevant information to ensure an appropriate servcie to service users. The registered manager and care provider must ensure that the spindles are secured to the bannister in the main house. The registered manager and provider must ensure that the cracked tile in the kitchen is eplaced in line with the current type. The registered manager and care provider must ensure that the vent in the laundry room is repaired. The registered manager and care provider must ensure that the bath panel identified in the bathroom in the main house is replaced. The registered manager and provider must ensure that the door handles on the wardrobe of the identified service user are replaced. The registered manager and care provider must ensure that light bulbs are fitted in identified service users bedside lamps. The registered manager and care provider must ensure that the en suite bathroom in the main house (which has had the shower removed) which has a damp area behind the wc needs to be investigated, repaired and redecorated. 8/10/05 15/10/05 1/10/05 1/10/05 1/10/05 1/10/05 1/10/05 1/10/05 1/12/05 Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 25 16. 24 23 (2) c 17. 24 23 (2) b 18. 24 23 (2) b 19. 20. 24 24 23 (2) b 23 (2) b 21. 24 23 (2) a 22. 33 18 (1) a 23. 39 24 (1) b 24. 42 23 (2) c 25. 42 23 (4) c (3) 23 (4) (c) (1) 26. 42 The registered manager and care provider must ensure that the cooker in the main house has the cooker knob replaced to allow all cooker plates to function. The registered manager and care provider must ensure that handles are put on kitchen cupboards in the flat. The registered manager and care provider must ensure that the bathroom door in the flat is replaced. The registered manager and care provider must ensure that the boiler door in the flat is repaired. The registered manager and care provider must ensure that the exterior rendering around the door to the flat is investigated and repaired. The registered manager and care provider must ensure that the bathroom in the flat is updated and the shower fitted. The registered manager and care provider must ensure that there is a copy of the duty rota showing staff working in the home and a record of whether the hours were actually worked. The registered manager and care provider must ensure that the feedback obtained from the quality assurance review is compiled into a report and acted upon. The registered manager and care provider must ensure that the boiler is brought into line with current standards. The registered manager and care provider must ensure that fire notices contain all relevant information. The registered manager and care provider must ensure all door closures work effectively. 8/10/05 1/10/05 1/10/05 1/11/05 1/11/05 1/1/06 1/10/05 1/11/05 Immediate Requireme nt issued. 1/9/05. Immediate Requireme nt issued. 20/8/05. Immediate Requireme nt issued. Page 26 Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 25/8/05. 27. 42 23 (4) v The registered manager and care provider must ensure that all recommendations outlined by UK Fire in their latest risk assessment need to be implemented. The registerd manager and care provider must ensure that the Emergency Planning Authority are consulted about fire safety arrangements in the home and their advice acted upon. The registered manager and care provider must ensure that the filing cabinet blocking the passageway on the stairs is removed. The registered manager and care provider must ensure that the glass panelling in the stairwell of the entrance to the flat is replaced. The registered manager and care provider must ensure that the defective fridge/freezer is replaced. The registered manager and care provider must ensure that a reputable pest control agency inspects the agency regularly. Immediate Requireme nt issued. 1/9/05. Immediate Requireme nt issued. 1.9.05. 1/10/05 28. 42 23 (4) v 29. 24 23(1)(b) 30. 24 23(2) (b) Immediate Requireme nt issued. 22/8/05. Immediate Requireme nt issued. 1/9/05. 1/10/05 31. 24 23(2) (c) 32. 24 23 (5) 33. 34. 35. 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 Good Practice Recommendations Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 27 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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 Parkcare Homes Ltd - Station Road 20050818 Parkcare Station Road X00023 UN Stage 4 S10591 V212891 G59.doc Version 1.40 Page 28 - 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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