Inspection on 25/10/07 for Parkfields

This inspection was carried out on 25th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Parkfields 08/01/07

Parkfields 11/05/06

Parkfields 15/12/05

Parkfields 12/05/05

Parkfields 05/10/04

Parkfields 01/06/04

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

CARE HOMES FOR OLDER PEOPLE Parkfields 556 Wolverhampton Road East Parkfields Wolverhampton West Midlands WV4 5AA Lead Inspector Rosalind Dennis Key - Unannounced Inspection 25th October 2007 09:30 X10015.doc Version 1.40 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 Parkfields DS0000017196.V350331.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 Older People. 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. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Parkfields Address 556 Wolverhampton Road East Parkfields Wolverhampton West Midlands WV4 5AA 01902 621721 01902 339915 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) Dr Mohan Lal Passi Dr Uma Passi Miss Cheryl Fenton Care Home 49 Category(ies) of Physical disability (49), Physical disability over registration, with number 65 years of age (49), Terminally ill (3) of places Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No number division between categories except 3 (only) palliative care. Up to a maximum of 7 beds may be used for intermediate care. Date of last inspection 8th January 2007 Brief Description of the Service: Parkfields Nursing Home is a privately owned care home registered with the Commission for Social Care Inspection to provide nursing care to 49 people who may have a physical disability. The home also provides respite care and admits people on a ‘step down’ basis from hospital-although registered with CSCI to provide intermediate care, the home is not currently providing the intensive rehabilitation associated with intermediate care. Parkfields Nursing Home is owned by Dr Mohan Lal Passi and Dr Uma Passi. Ms Cheryl Fenton is the registered manager and has day to day management responsibility for the home. Parkfields Nursing Home is a two-storey, purpose built accommodation set in attractive grounds with parking at the front and gardens to the side and rear. Twenty-two bedrooms have en-suite facilities, all other bedrooms have a hand-wash basin. The communal areas comprise of 3 lounges and a separate dining area. A lift provides access between floors and the building has a number of level access points to the garden. The Home is situated close to Wolverhampton city centre, on a public transport route and with shops and local services nearby. At the time of this inspection the manager reports that the current weekly fee ranges from £347 -£482, depending on the needs of the individual. The reader may wish to obtain more up to date information from the care service. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted by one inspector over a period of around seven hours. During the inspection, time was spent speaking with people living at the home, speaking with staff, management as well as looking at records. The inspection also focussed on observing staff in their work. Comments and views were collated from people living at the home, staff on duty and visitors, and the content of these is reflected within the individual outcome groups in the report. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with us areas that they believe they are doing well. It is a legal requirement that the AQAA is completed and returned to the commission-the manager returned the AQAA within the required timescale. Scrutiny of this document shows that the manager has some good ideas for developing and enhancing the service. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection What the service does well: Care plans are drawn up with the individual and generally provide staff with the information they need to meet individual needs. Most people spoken with during the inspection provided very positive comments about Parkfields Nursing Home and how the care staff meet their needs-comments included ‘I’m very happy with my care’ ‘ staff are kind and caring’’ I can’t fault them in anyway’. Training opportunities within the home are good and this ensures that staff are appropriately skilled and competent to carry out the duties for which they are employed. The staff team is culturally diverse, some staff speak a variety of languages, which helps in the communication with people from different ethnic backgrounds. The standard of the environment is good providing people with an attractive, clean and homely place to live. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Three requirements and four recommendations for improvement were made as a result of this inspection. The drugs fridge records show that staff have not responded when the temperature has been too low. Staff must be made aware of the required temperature range and of the procedure to follow should the temperature fall outside this range. This is to ensure that medication is stored correctly and to prevent people being placed at risk of harm from receiving ineffective medication. The home has a recruitment procedure in place however one reference could not be located for one member of staff and for another person it was not clear that the reference which had been obtained was from the person’s most recent employer. Improvements are needed to ensure the process is consistently robust. Staff had completed daily checklists to indicate that bed rails were correctly fitted, which was not the case and the home is required to ensure that bed rails are assessed, fitted and maintained by a competent person in accordance with specific guidance. The manager was informed where to locate the guidance. The home has developed ‘feedback questionnaires’ but also needs to look at ways to keep people living at the home and/or their significant others informed of action taken by the home in response to any feedback. Care plans would be enhanced by incorporating individual short term and long term goals so that staff are aware of the methods needed to maximise a person’s independence and support self-care. The home also needs to develop robust processes used to monitor the progress and deterioration of wounds. The manager was advised to obtain a copy of the new local area adult protection policy. This is to ensure that the manager and staff are kept informed of the processes to follow should any incident or allegation of abuse occur. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home is registered with CSCI to provide intermediate care, the home is not currently providing this service therefore Standard 6 is not applicable at this time. Quality in this outcome area is good. The home has a good assessment and admission procedure, which ensures that the home is able to meet people’s needs This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation of three people’s care files shows that an assessment of a persons’ needs is undertaken by senior staff prior to the person’s admission to the home-this may completed when staff visit the person in hospital or in their own home. People and their significant others are given opportunity to visit Parkfields Nursing home prior to their admission although for some people this is not always possible. A person recently admitted to the home spoke of their satisfaction with the admission procedure. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 10 Information leaflets on the home were seen in the reception area, the manager reported that the statement of purpose is currently in the process of being updated and was therefore not reviewed at this inspection-a request is made for this to be sent through to CSCI on completion. The home continues to provide care to people on a ‘step down’ basis, which is generally for individuals transferred from hospital who are waiting for a care package to be arranged before returning to their own home or sheltered accommodation. The home confirms that it refers people to appropriate health and social care professionals for rehabilitative support. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. Care plans are drawn up with the individual and generally provide staff with the information they need to meet individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Most people spoken with during the inspection provided very positive comments about Parkfields Nursing Home and how the care staff meet their needs-comments included ‘I’m very happy with my care’ ‘ staff are kind and caring’’ I can’t fault them in anyway’. Three people spoke of how the care varied, depending on which staff were on duty commenting ‘some staff are more attentive than others’. Observation of care records shows that care is planned according to information given by the person and/or their significant other. Each file Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 12 checked contained a range of care plans and risk assessments, and these had been reviewed on a regular basis. The home continues to look at different ways to plan and review care, which has resulted in many documents in people’s care records. It was discussed with the manager that it may be beneficial to ‘streamline’ care records so as to assist staff in their record keeping and make it easier for people who may wish to look at their care records. Forms were present in people’s care records, which had been signed by the individual to confirm that staff had explained initial care plans. Information provided by the manager describes how the home uses a ‘person-centred’ care planning approach-the care records seen did not always show this approach. Care records were not clear in identifying individual short term and long term goals or the methods needed to maximise a person’s independence during respite or interim care. Information provided by the manager describes how the home involves physiotherapists for people who wish to have rehabilitation support and a physiotherapist was seen visiting the home during inspection. Sufficient and appropriate equipment was seen available throughout the home to promote tissue viability and to move people safely. However when looking at the way the home records information regarding wound care, it was seen that the home does not have an adequate system in place to monitor the progress of wounds, such as through regular measurements to establish whether healing is taking place. Several staff had recorded descriptions of wounds on one person’s chart, as the entries had not been dated or signed it was unclear when particular wounds had occurred. The manager was advised to seek the advice of the tissue viability specialist and to implement a process whereby wounds can be monitored more effectively. Some staff working within the home have a recognised palliative care qualification, staff training records also show that community hospice staff have recently provided additional training sessions for staff on palliative care. Medication administration is restricted to trained staff and observation of a selection of Medication Administration Record charts found them to be completed accurately. A tube of cream was found in one person’s room for which they were not prescribed and this was brought to the attention of the manager. The home is monitoring the temperature of the medication room and this shows that it remains satisfactory. The drugs fridge records show that the fridge has been below the required temperature range with no evidence to show that staff had responded to this. The manager has conducted an audit of medication practices on an annual basis and is advised to increase the frequency of this audit. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. Daily routines are flexible and people are offered a choice of varied activities. The home provides meals that offer variety and cater for different cultural and nutritional needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Notices were seen around the home advertising different activities, such as Bingo, music and movement and craft activities. People spoke of how they enjoy these activities and how the home supports them to access events in the wider community if they so wish, such as attending church, or a local day centre. The home does not have a staff member designated to organise social and leisure activities, instead an outside entertainer visits three times per week-the ‘self-assessment’ completed by the manager describes how the home is planning to have activities four times per week, it is considered that the frequency of activities does need to be kept under review, for most of the Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 14 inspection people were observed seated in the lounge areas with little constructive activity going on. The minutes of a ‘Residents Meeting’ in the summer show that people had asked about a new television in one of the lounges, two people also raised this during the inspection as one television is not fully operational and the home is advised to act on these comments. Observation of recently completed ‘satisfaction surveys’ show that people had confirmed within their feedback that they are given choices in their daily lives, such as what time to get up, go to bed. The home confirms it operates an ‘open visiting’ policy although a number of notices were seen which were suggestive of a more restrictive approach in the evening-the manager sought to remove these. Visitors who were spoken with during the inspection spoke of their satisfaction with the home. Menu plans show that the home provides varied diets that also meet the cultural needs of people living at the home. People confirmed that they are offered choices at each meal and this was seen during the serving of tea when two people stated they did not feel hungry-staff offered a variety of alternatives to try to tempt the people to eat. All people spoken with described the food as good. Staff were observed to be courteous and attentive to people’s needs, providing assistance and support to those who required help with eating and drinking. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. The home ensures that people have access to a clear complaints procedure, which enables concerns or complaints to be dealt with promptly and professionally. Staff are provided with training to equip them with the knowledge and skills to safeguard adults from the risk of abuse or neglect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure, which is clearly displayed in the reception area. People had responded that they are aware of the complaints procedure within recently distributed ‘satisfaction survey’s’ and during the inspection people spoke of how they would feel comfortable with raising any issues with the manager or other staff. The manager confirmed that the home has not received any complaints within the past 12 months and CSCI has not received any recent complaints in respect of the service. Information on advocacy services is available and information provided by the manager shows that the home recognises the importance of newly introduced mental health legislation (the Mental Capacity Act) and the manager spoke of how she is planning to cascade this training to all staff. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 16 Observation of staff files show that staff are provided with a handbook on ‘Recognition and Prevention of Abuse’, which forms part of staff training on adult protection. It was established that the home does not have a copy of the recently updated local area adult protection policy and the manager was recommended to obtain a copy of this procedure and make staff aware of its location Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. The standard of the environment is good providing people with an attractive, clean and homely place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has sufficient communal rooms, to provide people with alternative places to access if they wish- these rooms have been redecorated since the last inspection and were found to be clean. People spoke of their satisfaction with their bedrooms and personal possessions, photographs and pictures create a ‘homely feel’ to individual rooms. All parts of the home are accessible to people who have mobility difficulties and there is level access to a large patio area and gardens. Sufficient moving Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 18 and handling equipment is available for people who need assistance to move. Observation of a selection of bedrooms, bathrooms and en-suite facilities shows that staff have a good approach to ensuring that the home is kept clean and tidy. Information provided by the manager shows that around 50 of staff have received training on the prevention of infection and the manager spoke of how training for other staff is being sought. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is on balance good. Training opportunities within the home are good which ensures that staff are appropriately skilled and competent to carry out the duties for which they are employed. The home has a recruitment procedure in place however improvements are needed to ensure the process is consistently robust. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was established that staffing levels are usually 7or 8 carers plus two nurses on a morning shift, 6 or 7 carers and two nurses in the evening and around 5 staff on at night –which includes 1 or 2 trained nurses. Most people spoken with felt that there are sufficient staff on duty to meet their needs. Two people viewed that staffing levels are not always adequate- one of these people described several occasions where staff had been unable to assist them to mobilise to the toilet promptly, this individual spoke of the negative impact this had on their dignity-these comments were brought to the attention of the manager. Staff spoke of how staffing levels are usually sufficient to meet people’s needs. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 20 Throughout the inspection staff appeared to be working hard, there was a notable ‘busy’ atmosphere in the home with visits from relatives and health and social care professionals taking place and it was observed that a number of people living at the home have a high dependency of need. As the home does not have a receptionist/administrator, staff take responsibility for answering phone calls and opening the front door-it may be beneficial for the home to look at the utilisation of other staff to avoid taking care staff away from their duties. A discussion with the manager confirmed awareness that staffing levels need to be calculated according to the dependency and needs of the people living at the home. Observation of three staff files shows that staff do not start work at the home until a satisfactory CRB disclosure has been obtained, however only one file demonstrated that suitable references had been obtained prior to the person starting work. Only one reference was present on file for one member of staff recently appointed by the home and for another, the reference did not provide confirmation that it was from the person’s most recent employer or the most senior person in the organisation. Photocopies of nurse’s registration cards were present on file and the manager confirmed that telephone contact is also made with the Nursing and Midwifery Council (NMC) to confirm registration-the manager was advised to keep a record of the dates these checks are made on each individual staff file. Since the last inspection the home has improved the staff induction process and in addition to training in safe working practice topics, records show that staff have attended study sessions in topics such as wound care, continence and palliative care. The manager has started recording and planning training on a training matrix and observation of staff supervision records show that when training needs are identified, action is taken to ensure training is provided. Care staff spoke of how regular training opportunities are available and that there is ongoing support to study for NVQ in care-information provided by the manager shows that 60 of staff have achieved NVQ Level 2 in care. The staff team is culturally diverse, some staff speak a variety of languages, which helps in the communication with people from different ethnic backgrounds. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. The manager has the skills and knowledge to lead the staff team and manage the home. The home has systems in place to protect people from harm however by not adhering to current guidance regarding the safe use of bed rails the health, safety and welfare of residents is not fully promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager, Cheryl Fenton is a registered nurse with a range of supporting qualifications, skills and experience. A deputy manager provides continuity in the day to day running of the home if Cheryl Fenton is not available. People Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 22 living at the home, visitors and staff spoke of their satisfaction with how the home is managed. The manager is not included in the staffing levels, meaning there is opportunity to complete managerial duties, however it was established that a lack of administrative assistance sometimes impacts on managerial time. The manager has also had to complete some of the routine checks, such as water temperatures as the home’s maintenance person has not been available. Observation of ‘satisfaction surveys’ shows that the home is giving people opportunity to comment on the service and the care received. People have provided very positive feedback within the surveys about the care they receive, the staff, food and how privacy and choice is respected. Although the manager collates responses, the process would be further enhanced by publishing the overall results of surveys so that people are regularly kept informed of the results and any action taken by the home, where appropriate. The views of staff and health/social care professionals are also included in the home’s quality assurance processes. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the home for completion. The AQAA is a selfassessment and a dataset that needs to be filled in once a year by all providers. The manager completed the AQAA and returned it the commission within the timescale given. The AQAA shows that the manager has some good ideas for improving and enhancing various aspects of the service, such as qualified staff providing teaching sessions for care staff, improving the care planning system and updating the pre-admission assessment in line with the Mental Capacity Act. Since the last inspection a safe has been fitted and observation of a selection of individual financial records demonstrates that the home has robust systems in place to safeguard people’s financial interests. During tour of home equipment appeared well maintained, however most of the bed rails seen were not fitted correctly resulting in an excessive gap at the head end of the bed, some connections were loose and one person only had one bed rail on their bed. Staff had completed daily checklists to indicate that bed rails were correctly fitted, which was not the case. Records show that a specialist company had undertaken an audit of the home’s beds, mattresses and bed rails in April 2007, and the manager spoke of how the company had shown her how bed rails should be fitted-the manager has then cascaded this to staff. The manager was informed that all staff need to be made aware of specific published guidance on the safe use of bed rails and information was given on where to locate this. The fire officer visited in September 2007 and the manager spoke of how fire safety deficits are being addressed-‘fire marshal’ training is booked for Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 23 November and a self-closure device is to be fitted to a door for someone who prefers to have their bedroom door open at night. Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13(2) Requirement The temperature of the drugs fridge must be maintained at between 2 and 8°C and the registered person must ensure that staff are aware of the required temperature range and of the procedure to follow should the temperature fall outside this range. This is to ensure that medication is stored correctly and to prevent people being placed at risk of harm from receiving ineffective medication Two written references must be obtained prior to a person starting work at the care home. This is required by legislation and is to protect people from the employment of inappropriate staff. Bed rails must be assessed, fitted and maintained by a competent person in accordance with MHRA/HSE guidance. This is to protect the person from the risk of harm and promote their safety Timescale for action 10/12/07 2 OP29 19 Schedule 2 (3) 10/12/07 3 OP38 13(4)(c) 10/12/07 Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 26 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 OP7 Good Practice Recommendations The home is advised to develop person-centred care plans, which incorporate individual short term and long term goals. This is to ensure staff are aware of the methods needed to maximise a person’s independence and support self-care. The home is advised to consult with the local tissue viability specialist to develop a robust process to monitor the progress or deterioration of wounds. It is strongly recommended that the home obtain a copy of the new local area adult protection policy. This is to ensure that the manager and staff are kept informed of the processes to follow should any incident or allegation of abuse occur It is recommended that the home looks at ways to increase access to the results of ‘satisfaction’ survey’s-this is to keep people living at the home and/or their significant others informed of action taken by the home in response to any feedback 2 3 OP8 OP18 4 OP33 Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection 1st Floor Chapter House South Abbey Lawn Abbey Foregate Shrewsbury SY2 5DE 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 Parkfields DS0000017196.V350331.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!