Inspection on 27/04/06 for Parkcare Station Road

This inspection was carried out on 27th April 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Parkcare Station Road 11/04/08

Parkcare Station Road 03/05/07

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 Homes (No 2) Ltd (Station Road) 8 & 8a Station Road London N21 3RB Lead Inspector Wendy Heal Key Unannounced Inspection 27th April 2006 10:30 Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 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 Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 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 Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Parkcare Homes (No 2) Ltd (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 Craegmoor Homes Ltd Mrs Tunay Arslan Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 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 One specified service user who is over 65 years of age may remain accommodated in the home. The home must advise the regulating authority at such times as the specified service user vacates the home. 8th November 2005 2. 3. Date of last inspection Brief Description of the Service: 8 & 8a 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 years. 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 are 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 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 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 Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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. The inspector undertook a tour of the building spoke with service users and members of the staff team. The inspector gained further information by an inspection of the documentation kept in the home, including care plans and health and safety documentation. The manager assisted the inspector throughout the day. The inspector would like to thank the service users present during the inspection, the manager, staff and service users for their openness and participation. What the service does well: What has improved since the last inspection? Care plans are up to date and being signed by service users were possible. The wishes of service users in the event of their death are being recorded on their file. A cover has been placed on cables to safeguard the health and safety of service users. The toilet has had the flooring replaced and been decorated. The vents in the bathrooms and toilets have been cleaned. The quiet room in the main house has been decorated. The cooker in the flat that posed a health and safety risk has been replaced. The boiler and heating system in the main house and flat have been replaced and the certificate has been found to be in order. The information obtained from the quality assurance review have been acted upon and compiled into a report. All recommendations outlined in UK Fire Risk Assessment have been implemented subject to advice from the Emergency Planning Authority. All door closures are now effective. The Service User Agreement has been updated. The service users now live in a pleasant safer environment. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 6 What they could do better: Unmet requirements impact upon the welfare and safety of service users failure to comply by the timescales will lead to the commission For Social Care Inspection considering enforcement action to secure compliance. Food products must be regularly date checked and food products identified as out of date must be disposed of properly to ensure the health of service users is not compromised in any way. The en- suite bathroom in the main house, which has the shower removed and has a damp area behind the WC must be investigated by a qualified person and redecorated to ensure that the quality of life for the service user is not impacted upon and their well being is not put at risk. The bathroom in the flat must be updated and a shower must be made available to ensure the needs of all service users are being catered for, as a request has been made by an identified service users to have access to a shower. The bathroom on the top floor of the main house needs to be updated. A qualified person must inspect the cracks inside the door of the main flat and the en suite bathroom on the top floor of the main house to ensure that there are no concerns in relation to the structure of the building, which can impact on service users wellbeing. Care plans need to include the actions agreed at review meetings, to ensure that the changing needs of service users are met and staff, work in a consistent way. Service users who refuse to attend medical appointments must have a risk assessment in relation to this. The Complaints book and Adult Protection Procedures must be available for inspection, to ensure the welfare of service users is safeguarded and that staff have adequate knowledge and access to Adult Protection Procedures. One identified service user needs to have his room redecorated. The laundry room needs to be redecorated. The sofa in the quiet room needs to be cleaned. The en suite shower on the top floor of the main house needs to be decorated. Fire doors must not be propped open as this endangers the health of service users in the event of a fire Magnetic door closures should be considered particularly in relation to the lounge door. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 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 Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5, Quality in this outcome area is good. Service users are given 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 individual service users aspirations and needs. The service users have an individual contract of terms and conditions, which assists service uses to have an understanding of what they can expect from the organisation and vies versa. EVIDENCE: Since the previous inspection there have been no new admissions to the home. The inspector looked at the statement of purpose, which is up to date. The service has a service user guide. The homes Service User Agreement clearly specifies the terms and conditions of the home including details of the notice period and have been recently updated. Service user care plans are being reviewed on a regular basis and are now being signed by service users where possible. This was a requirement made at the previous inspection, which has now been met. The care plans need to contain the actions agreed at review meetings to ensure the service users changing needs are met, and a consistent approach is adopted by all staff. A requirement has been made in relation to this. Service user files contained assessment information that is being reviewed on a regular basis. The manager and staff interviewed showed they had a good understanding of individual service users needs and could talk in detail in relation to their role. The service users spoke very positively in relation to staff and the support they receive. One service user has regular two weekly meetings with the manager as the service user is having difficulties at Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 10 college and at home. The service user said she could be “a bit stubborn and found the support good.” On the day of the inspection a prospective service users parents had come to see the home to see if it would be a suitable placement for their son. The manager spent some time speaking with the family and answering their questions. The inspector also spoke with them and answered questions in relation to the role of an inspector. The family had been provided with information about the home by their son’s allocated social worker. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality in this outcome area is good. This service is good at assisting service users to make decisions about their daily lives. The service is good at supporting service users to take risks to develop an independent lifestyle. Service users are consulted on, and participate in, all aspects of life in the home. The service is good at maintaining service users confidentiality as service users information is handled and kept appropriately. EVIDENCE: Service users care plans were inspected. They were clear to read. The manager is endeavouring to keep them up- to- date. The care plans of all service users evaluate all aspects of living in the home. The needs are identified as well as the aims to achieve a care intervention and the care plans are being evaluated on a regular basis. The plan specifies the area in which service users make decisions about their lives with assistance. The risk assessments to show potential risks for service users are being reviewed; the areas covered include stealing other people’s belongings, making racist comments and challenging behaviours. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 12 Service user meetings are taking place and discuss issues relating to the home. The inspector saw evidence of meetings held and minuted by service users. They had laid down the ground rules in relation to service users who live in the flat entering the main home and what the expectations are of them when they do this. There are also agreements made by service users in the independence flat in relation to when service users can and cannot enter each other’s bedrooms, these were positive actions taken by service users living in the flat. This process allowed for triggers to be identified that were causing friction and incidents to take place. Service user information is handled appropriately. The main files are kept in the office and information stored on computer is accessed by a password. The inspector observed the level of confidentiality in the home and is satisfied that the staff, at Station Road keep all service user information secure. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17, Quality in this outcome area is adequate. Service users are being supported to broaden the activities they participate in within the community. Service users are part of the local community and are encouraged to take part in age peer and culturally appropriate activities. Service users are supported to choose healthy nutritious meals. However food was not stored appropriately and was not within its use by date, which will impact on the service users health. EVIDENCE: At Station Road five of the service users activity records were inspected. Service users attend day services ranging from one day per week to five days per week. A number of service users travel independently. The care plans reflect how the service users are supported to develop their independent living skills, are specific to service users and are kept up to date. On the day of the inspection five service users spoke with the inspector, both on a one to one basis and in groups. Several discussed their day care arrangements. One service user has been having difficulties at college, two weekly meetings are taking place these identify the areas the service user Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 14 needs to work on. These meetings also explain that there are consequences for the young persons actions and also have guidelines and identify further action to be taken which includes how the young person wishes to be supported. The guidelines have been agreed and signed by the home and service user. Service user contact varies ranging from personal visits to telephone calls. The service users use local pubs and shops. Some service users attend church on a regular basis. On the day of the inspection two service users were going to lunch and then shopping. Another service user was going out with a member of staff he benefits from one to one support, which has increased his wish to take part in community activities. There was a notice on service users bedroom doors 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 service users have a key to their room. The inspector also saw the minutes of a meeting were the service users in the main house had set out the ground rules for the service users in the separate independence flat entering their home. Staff was aware of service users preferences in relation to meals and negotiated with service users in relation to their menu and diet. The menu of food available, which was inspected, was wholesome and nutritious. On the day of the inspection the kitchen was clean and tidy. The fridges were inspected and open food stored in the fridge was not labelled properly and was not within its use by date. A requirement has been made in relation to this. The inspector saw evidence of colour coded chopping boards to prevent cross infection. The manager is going to obtain colour coded chopping knives now that the inspector has explained their relevance in relation to preventing cross infection. One service user has been referred to an obesity clinic and has been on courses to explain the importance of what you eat and how it impacts on people’s health to aid the service user to manage their diet with support. Service users benefit from a mixed staff team who bring a range of different ideas to the home in terms of food preparation. This means that service users have access to different types of food than they may otherwise experience. Staff interacted with service users and there was a warm and friendly atmosphere in the home. One service user said “I miss the staff when they are not here because they are on holiday or on a day off.” Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19,20,21, Quality in this outcome area is adequate. Service users receive personal support in a way they prefer and require, which ensures their individual rights and choices are respected. There is good support provided to service users to access healthcare appointments. However were service users fail to attend appointments a risk assessment must be completed. The process for administering medication is effective and promotes the good health of service users. The wishes of service users in the event of their death are recorded to ensure their wishes are respected. EVIDENCE: The record of healthcare appointments for each service user was inspected. They showed they are being supported to receive their individual healthcare checks. When service users refuse to attend medical appointments a risk assessment must be completed to minimise the risks to the service user and identify action to be taken which may assist to resolve the difficulties the service user has. A requirement has been made in relation to this. Service user preferences in relation to how they prefer their personal care to be provided are highlighted in their individual care plans. The medication and administration records were inspected. The medication had been signed for on the MAR sheets. The medication cabinet was inspected and Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 16 found to be in order. Staff had received medication training to ensure that service users are protected by the homes medication procedures. Service users wishes are recorded on their files in the event of their death in most cases, were this is not possible due to the distress it would cause service users their parents wishes have been noted in an attempt to respect the service users wishes and their families as far is possible. Service users were appropriately dressed at the time of the inspection. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is poor. Service users cannot be confident that their views are listened to and acted upon since the recording and action taken was not available for inspection. The adult protection procedures could not be located which affects the ability of staff to fully protect service users from abuse neglect and self-harm. EVIDENCE: At the time of the inspection the inspector was unable to look at the complaints file, as it could not be located. The staff at the home had attended an adult abuse and protection of vulnerable adults training. The manager could not locate a copy of the adult protection procedures for the home. A requirement has been made in relation to these issues. Service user finances were not inspected on this occasion. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27 29,30 Quality in this outcome area is poor. Improvements in the home have been made further action is needed to ensure the home is comfortable and homely for all of the service users. Service users bedrooms suit their needs and lifestyles and promote their independence. Service users bathrooms do not meet their individual needs. Service users have the specialist equipment they require to maximise their independence EVIDENCE: The home offers an appropriate domestic type environment. During a tour of the building the inspector was able to look at the service users bedrooms. The service users had given their permission for the inspector to enter their bedrooms. The service users bedrooms were furnished to suit their needs and have been personalised further since the last inspection. The staff had sought the wishes of the service users and supported service users to buy new televisions, and in some cases new music centres and DVD players. Two service users discussed their love of music and said, I really like my new television.” One identified service user needs his room to be decorated and the flooring to be replaced. The laundry room needs to be redecorated. The en suite shower Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 19 room on the top floor needs to be decorated. The service user who specifically uses this bathroom said, “I would like my shower room to be as nice as my friend who lives at Station Road. The sofa in the quiet room needs to be cleaned. The bathroom on the top floor needs to be updated. Requirements have been made in relation to all of the above. At the last inspection a number of maintenance tasks were identified: and had been complied with a new cover has been placed on the exposed cables outside the patio doors of the main house to safeguard the service users. A hole in the wall of an identified service users bedroom has been repaired. The toilet opposite the laundry room has had the flooring replaced and has been decorated. The vents in the bathroom and toilets had been cleaned. The quiet room in the main house has been decorated. The recommendations outlined in the fire risk assessment have been implemented and this has been subject to advice from the Emergency Planning Authority. The information obtained from the quality assurance review has been compiled into a report and acted upon. The en suite bathroom in the main house, which has the shower removed has a damp area behind the WC. This needs to be investigated by a qualified person and this area needs to be redecorated. The inspector could not inspect the room at the time of the inspection as the service user had left the building with their room key. A qualified person has not investigated the cracks inside the door of the flat and the en suite bathroom on the top floor of the main house. This requirement has been restated. The bathroom in the main flat has not been updated and made safe a new shower has not been fitted. This requirement has not been met. Due to the impact of these facilities on service users and the service users request for the bathroom to be updated and repeated requests for this work to be completed an immediate requirement was made at this inspection. A number of immediate requirements were issued at the last inspection. The cooker in the flat has been replaced as it posed a health and safety risk to service users. The new boilers have been fitted in both the flat and main house and an up to date certificate has been sent to the commission for social care inspection. All door closures are now effective. The fire officers have attended the home at the inspector’s request and the action required in the fire officer’s report has been completed. These immediate requirements have been met and safeguard service users welfare. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34, 35,36, Quality in this outcome area is adequate. Staff was not adequately qualified as staff are only just having access to NVQ assessors, which means that service users are not supported by fully qualified staff which impacts on the quality of the service offered. Service users are safeguarded by the home’s recruitment policy and procedures. Service users benefits from the supervision being up to date as this means staff are well supported and supervised. EVIDENCE: The staff rota was inspected and found to be in order. Staff was observed to have a clear understanding of their roles and responsibilities, from the conversation the inspector had with them. Service users are not supported by qualified staff due to the fact that they have not had access to NVQ assessor’s the manager informed the inspector that the organisation is attempting to rectify this issue and this has been confirmed by the area manager. Supervision records were inspected. Staff are receiving regular supervision, which is signed by all parties. This ensures a professional and consistent approach is undertaken by the staff team and assists the development of service users. The staff files were inspected and contained all the criminal records bureau checks, staff references, and the required staff identification records. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 21 Regular staff meetings are taking place. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42 Quality in this outcome area is poor. Service users can be confident, that their views underpin the development of the home. All appropriate health and safety measures need to be in place to ensure the safety and welfare of service users is maintained. EVIDENCE: During a tour of the building, the inspector noted that all fire doors were not closed but propped open this would fail to protect service users in the event of fire taking place. The inspector was particularly concerned as a fire has recently taken place in the home. A requirement has been made in relation to this. The fire drills, fire alarm tests and the fire alarm systems were all found to be in order. Fire exits were clear and free from any obstruction. The fire safety notices contained the relevant information. The boiler certificate was seen and found to be in order. The management of the home has shown positive improvements since the last inspection. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 23 The manager has completed a Quality Assurance Questionnaire and acted on the areas identified for action. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 24 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 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 3 32 X 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 3 X 3 X 3 2 X Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 25 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 YA6 Regulation 15 (2 ) (b) Requirement The Registered provider must ensure that the actions agreed at review meetings are incorporated into the care plan. The Registered Provider must ensure that food products used are regularly date checked and that food products identified as out of date are disposed of properly. The registered provider must ensure that the en suite bathroom in the main house (which has had the shower removed.) Which has the damp area behind the WC needs to be investigated by a qualified person and then decorated. .Previous time scale 01/01/06 The Registered Provider must ensure that an appropriately qualified person must investigate the cracks inside the door of the flat and the en suite bathroom on the top floor of the main house. Previous timescale not met 15/01/06 DS0000010591.V287751.R01.S.doc Timescale for action 20/06/06 2. YA17 16 (2) 20/05/06 3. YA24 23 (2) (b) 27/06/06 4. YA24 23 (2) (b) 15/06/06 Parkcare Homes (No 2) Ltd (Station Road) Version 5.1 Page 26 5. YA24 23 (2) (a) 6. 7. 8. YA42 YA22 YA23 23 (4) (c) (i) 22 17 (2) 9. YA24 23 (2) (b) 10 YA24 23 (2) (b) 11 YA24 23 (2) (b) 12 YA24 23 (2) (d) 13 YA9 12 The Registered Provider must 18/05/06 ensure that the bathroom in the main flat must be updated and a shower fitted. Previous timescale not met 01/01/06 Immediate Requirement. The Registered Provider must 20/05/06 ensure that fire doors must not be propped open. The Registered Provider must 20/05/06 ensure the Complaints book is to be available for inspection. 20/05/06 The Registered Provider must ensure The Adult Protection Procedures must be available and kept at the home at all times. 01/07/06 The Registered Provider must ensure that the identified service users bedroom is decorated and the flooring is replaced. 01/08/06 The Registered Provider must ensure the laundry room is decorated. The Registered Provider must 10/08/06 ensure the en suite shower room on the top floor of the main house is decorated. The Registered Provider must 01/08/06 ensure the sofa in the quiet room of the main house is cleaned. The Registered Provider must 01/07/06 ensure that risk assessments are completed for service users who refuse to attend medical appointments. Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Parkcare Homes (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Southgate Area Office 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 (No 2) Ltd (Station Road) DS0000010591.V287751.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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