Inspection on 11/04/05 for Parkhouse Grange

This inspection was carried out on 11th April 2005.

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

Parkhouse Grange 12/03/09

Parkhouse Grange 28/10/07

Parkhouse Grange 27/07/06

Parkhouse Grange 03/11/05

Parkhouse Grange 23/08/05

Parkhouse Grange 04/05/04

Parkhouse Grange 22/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

Care Home For Older People Parkhouse Grange 47 Park Road Earl Shilton Leicestershire LE9 7EB Unannounced Inspection 8th March 2005 Commission for Social Care Inspection Launched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role. Inspection Methods & Findings SECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Parkhouse Grange Address 47 Park Road, Earl Shilton, Leicestershire, LE9 7EB Email address Name of registered provider(s)/company (if applicable) A.L.A. Care Limited Name of registered manager (if applicable) Mrs Regina Summerfield Type of registration Care Home No. of places registered (if applicable) 40 Tel No: 01455 851333 Fax No: 01455 851333 Category(ies) of registration, with (number of places) Dementia - over 65 years of age (20), Mental disorder, excluding learning disability or dementia (10), Mental Disorder, excluding learning disability or dementia - over 65 years of age (10), Old age, not falling within any other category (40), Physical disability (5), Physical disability over 65 years of age (5) Registration number C010000269 Date first registered Date of latest registration certificate 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 15th June 2004 YES YES 4.05.04 If Yes refer to Part C Parkhouse Grange Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 3 8th March 2005 11:00 am Kim Cowley ID Code 071390 Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspection Mrs Regina Summerfield (Registered Manager) Parkhouse Grange Page 2 CONTENTS Introduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s Agreement Parkhouse Grange Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Parkhouse Grange. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates. Parkhouse Grange Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Parkhouse Grange is a 40-bedded purpose built residential care home. It opened in 1996 and is situated in Earl Shilton, close to a range of local amenities. The home caters for older people, some of whom have mental health needs or physical disabilities. All bedrooms are single and 10 have ensuite facilities. There are three lounges, a dining room and a conservatory downstairs, and a lounge with an adjoining roof garden upstairs. The home is set in 1.5 acres of landscaped gardens. Parkhouse Grange Page 5 PART A SUMMARY OF INSPECTION FINDINGS INSPECTOR’S SUMMARY (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was an unannounced inspection that took place on a weekday. The home was warm, clean and tidy. Service users appeared relaxed and content. All those able to give their views made many positive comments about the home. One service user commented ‘I find this place very friendly’, and another said ‘There’s nothing to complain about here.’ Two Requirements remain outstanding from the last inspection. Continued failure to comply may result in regulatory action being taken against the Registered Person. The home was commended in one area. Choice of Home (Standards 1 – 6) These Standards were inspected at the last inspection on 4.05.04. Health and Personal Care (Standards 7 – 11) At the last inspection it was required that improvements were made to service users’ plans of care. At the time some were vague, did not give clear instructions to staff, and did not have appropriate risk assessments in place. At this inspection improvements were noted and those plans of care sampled complied with Standard 7. Medication records were inspected. They were found to be clear and well organised. At the front of the medication file is a list of the names of staff authorised to give out medication and a sample of each of their signatures. When medication is not administered staff give the reason why. Medication records are well kept and are commended. Daily Life and Social Activities (Standards 12 – 15) Activities held since the last inspection include: armchair aerobics, karaoke, a fish and chip supper night, a Mothers’ Day celebration, and vintage films on a big screen. A church service is held in the home once a month. The service users’ notice board was inspected. It showed the dates of the hairdresser’s forthcoming visits. The Link library bus was advertised. This calls at the home to supply books (including large print and ‘talking’), cassettes, CDs and DVDs. There was also a large display of ‘thank you’ cards on the board from the families of past service users. The Registered Manager said staff often sit in the lounges with service users in the afternoons and socialise. She said ‘We have a chat and a laugh. One Sunday we ate ice creams together. Sometimes we play “old time” music and have a dance. The important thing is that staff and residents have a chance to enjoy each other’s company.’ The home has two part-time cooks and three kitchen assistants. Lunchtime was observed. Service users were sitting at small tables, with co-ordinated tablecloths and serviettes, and fresh flowers. The menu was displayed next to the serving hatch. The meal consisted of a soup starter, followed by sausage casserole, or lamb and leek stew, with gravy, mashed potatoes, and peas. Dessert was chocolate sponge with custard. Service users’ comments about the meals included, ‘Lovely food – I like the puddings’, ‘There’s more food than we can Parkhouse Grange Page 6 eat’, and ‘The food is more appetising than I’ve had in other homes.’ Complaints and Protection (Standards 16 – 18) These Standards were inspected at the last inspection on 4.05.04. Environment (Standards 19 – 26) This Standard was inspected at the last inspection on 4.05.04. However one requirement remains outstanding from the last inspection. At present there is no secure area of the gardens suitable for service users who wander. The Registered Person agreed to create one when they applied last year to increase the number of dementia beds at the home. It is therefore disappointing that the garden remains unusable for service users who wander unless they are accompanied. The work must now be done as a matter of urgency. See Requirement 1. Staffing (Standards 27 – 30) At the last inspection concerns were raised by service users and visitors about the number of staff on duty and about staff attitudes. The Registered Manager has addressed these concerns. At this inspection staffing hours were found to exceed the minimum number recommended by the Residential Forum. Staff attitudes were found to be good. Staff were welcoming, enthusiastic about their work in the home, and appeared to have excellent relationships with service users. The Registered Manager said the current staff team is established and stable. All service users interviewed made positive comments about the staff including, ‘Everyone’s here to help me and make me happy’, and ‘The staff look after me.’ At the last inspection it was found that not all staff files contained photographs of the staff in question. A requirement was made for this to be rectified. This requirement has still not been met. The Registered Person must ensure that all staff files contain photographs. See Requirement 2. Management and Administration (Standards 31 – 38) At the last inspection some radiators in communal areas were found to be hot to the touch and to present risk to service users. The Registered Manager said following the inspection, and in response to the finding, a qualified person checked the boiler and the overall temperature turned down. At this inspection radiators were checked and fond to be warm, but not hot, to the touch. The home’s Fire Officer last inspected fire safety in the home on 10.01.05. A recommendation was made that the Fire Risk Assessment should be amended. The Registered Manager said this has been done. In a letter dated 9.03.05 the home’s Environmental Health Officer has asked ALA Care Ltd to improve and amend it’s corporate Health and Safety Policy. The Registered Manager said this is in the process of being done and the final document will be shown to the EHO for approval. Parkhouse Grange Page 7 Requirements from last Inspection visit fully actioned? If No please list below NO STATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for action The registered person must ensure that ‘external grounds which are suitable for, and safe for use by service users are provided and appropriately maintained’. To comply an area of the gardens must be made safe for service users who wander. 1 Reg 23(2)(o) OP19 2 19(4)(b) OP29 The Registered Person shall not allow a person to work at the care home unless ‘the employer has obtained in respect of that person the information and documents specified in (i) paragraphs 1 to 7 of Schedule 2’. To comply the Registered Person must ensure that staff files contain all the required documentation (including photographs). Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. Parkhouse Grange Page 8 RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). No one under the age of 55years may be admitted into the home in categories MD or PD. Service User numbers - No person falling within categories MD/MD(E) may be admitted to the home when there are 10 persons in total in these categories/combined categories already accommodated in the home. Service User numbers – No person falling within the category DE/E may be admitted to the home when there are 20 persons of that category already accommodated in the home. Service user numbers - No person falling within categories PD, PD(E) may be admitted to the home when there are 5 persons of these categories/combined categories already accommodated in the home. To be able to admit a named person in the category Sensory Impairment (over 65 years of age) as identified in correspondence with CSCI dated 10.05.04. Met (Yes / No) YES YES YES YES YES Parkhouse Grange Page 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office. STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action The registered person must ensure that ‘external grounds which are suitable for, and safe for use by service users are provided and appropriately maintained’. To comply an area of the gardens must be made safe for service users who wander. 1 Reg 23(2)(o) OP19 8.06.05 2 19(4)(b) OP29 The Registered Person shall not allow a person to work at the care home unless ‘the employer has obtained in respect of that person the information and documents specified in (i) paragraphs 1 to 7 of Schedule 2’. To comply the Registered Person must ensure that staff files contain all the required documentation (including photographs). 8.05.05 Parkhouse Grange Page 10 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard * Parkhouse Grange Page 11 PART B INSPECTION METHODS & FINDINGS The following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other (Specify) ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES YES NO NO YES YES YES YES YES YES NO YES NO YES NO YES 8 1 0 NO NO YES YES 17 0 8/03/05 11:00 5 Parkhouse Grange Page 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls) 0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable. Parkhouse Grange Page 13 Choice of Home The intended outcomes for the following set of standards are: • • • • • • 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. Standard 1 (1.1 – 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users’ guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the home’s service user’s guide. Range of fees charged From (£) X To (£) X Any charges for extras If yes, please state what the extra’s are: Key findings/Evidence YES Standard met? 0 This Standard was inspected at the last inspection on 4.05.04. Parkhouse Grange Page 14 Standard 2 (2.1 – 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Standard 3 (3.1 – 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Standard 5 (5.1 – 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Parkhouse Grange Page 15 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Not applicable as this home does not provide intermediate care. Parkhouse Grange Page 16 Health and Personal Care The intended outcomes for the following set of standards are: • • • • • The service user’s health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. 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. Standard 7 (7.1 – 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The home has a computerised care-planning package, which includes admission details, daily records, care plans, risk assessments, medical information (including medication), accidents, dietary needs, emotional reports, and interests. All senior staff have been trained to use this package. At the last inspection it was required that improvements were made to service users’ plans of care. At the time some were vague, did not give clear instructions to staff, and did not have appropriate risk assessments in place. At this inspection improvements were noted and those plans of care sampled complied with this Standard. It was also recommended at the last inspection that service users admitted on an emergency basis had interim plans of care until their full plans of care was produced. The Registered Manager said there have been no emergency admissions since the last inspection, but if there was in future she would ensure staff had some form of written interim plan of care to work to. The Registered Manager said staff use a person-centred approach to care planning. She said ‘We start with the person as a unique individual and get to know them. Some want hugs, others don’t. If they are challenging we encourage the positive side of their behaviour, and discourage the negative.’ Parkhouse Grange Page 17 Standard 8 (8.1 – 8.13) The registered person promotes and maintains service users’ health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence 8 0 Standard met? 3 The ‘Medical Information’ section of the service user plans is used to monitor physical health. All service users are weighed within one week of admission, and then as deemed necessary by the staff. The home uses ‘Waterlow’ scoring to determine the level of risk to service users of pressure sores. Staff then work with the local District Nursing team to provide appropriate care including the use of special mattresses and cushions, monitoring nutrition, and regular turning. Records are kept of staff intervention and recorded on a ‘Pressure Sore Management’ form. At present one service user is receiving twice-weekly visits from a District Nurse for dressings. The Registered Manager said that if she has concerns about a service users’ mental health she consults their GP who can then refer them to a consultant if appropriate. Records are kept in the ‘Emotional Report’ section of the service user plan of care. In discussions the Registered Manager gave examples of how service users’ entitlements to NHS services were pursued in accordance with the relevant guidance and legislation. The home’s awareness of service users’ rights in relation to the National Service Framework will be examined at the next inspection. A dentist and an optician visit the home regularly. The home uses the service of a private chiropodist who visits every six months. The Registered Manager said the home can arrange for an NHS chiropodist to visit if a service user requests this. Parkhouse Grange Page 18 Standard 9 (9.1 – 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 4 Key findings/Evidence Standard Met? The home has a policy for the receipt, recording, storage, handling, administration and disposal of medication. This is based on the UKCC standards for the administration of medication. The contract pharmacist last inspected the home on 25.01.05 when medication stock and MAR sheets were checked. No requirements or recommendations were made. The Registered Manager and the Head Senior train staff in medication administration. They undertake an in-house training course and must pass a practical and written test before they are allowed to administer medication unsupervised. The Registered Manager said that she and her Head Senior review medication records every week to ensure procedures have been followed and staff have signed records appropriately. They are also responsible for ordering/retuning medication and keeping the drugs trolley stocked. The Registered Manager said that the condition of service users on medication is monitored and if concerns arise these are recorded in service user plans and the GP informed. Medication records were inspected. They were found to be clear and well organised. At the front of the medication file is a list of the names of staff authorised to give out medication and a sample of each of their signatures. Six staff are authorised by a District Nurse to administer insulin and there is documentation to support this. When medication is not administered staff give the reason why. For example one service user prescribed a sleeping tablet was not given it because she was ‘asleep’ at the time it should have been given. Medication records are well kept and are commended. Parkhouse Grange Page 19 Standard 10 (10.1 – 10.7) The arrangements for health and personal care ensure that service users’ privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Respecting a service user’s privacy and dignity is featured in the staff induction programme. It is also in the home’s Charter of Residents Rights and the Philosophy of the Home, both of which are displayed in the foyer. The Registered Manager said that a service user’s preferred term of address is discussed when they are admitted at the home and recorded on their admission form. She said some service users like to be addressed formally, and others prefer their first names to be used. There is a payphone in the foyer and a phone point in every bedroom. Standard 11 (11.1 – 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Service users (or their families/friends) are asked their preferences and these are recorded in their plans of care. Some staff have been on a ‘Death and Bereavement’ course at a local undertakers. Staff offer support to families/friends and service users following a bereavement and can arrange contact with counselling organisations if required. Parkhouse Grange Page 20 Daily Life and Social Activities The intended outcomes for the following set of standards are: • • • • 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. Standard 12 (12.1 – 12.4) The routines of daily living and activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. 3 Key findings/Evidence Standard met? Activities held since the last inspection included: • Armchair aerobics (monthly) • Karaoke (every three weeks) • A fish and chip supper night • A Mothers’ Day celebration • Vintage films on a big screen A church service is held in the home once a month. The Registered Manager said she was in the process of organising an Easter Sunday tea for service users and their visitors with bible readings. The service users’ notice board was inspected. It showed the dates of the hairdresser’s forthcoming visits. The Link library bus was advertised. This calls at the home to supply books (including large print and ‘talking’), cassettes, CDs and DVDs. There was also a large display of ‘thank you’ cards on the board from the families of past service users. The Registered Manager said staff often sit in the lounges with service users in the afternoons and socialise. She said ‘We have a chat and a laugh. One Sunday we ate ice creams together. Sometimes we play “old time” music and have a dance. The important thing is that staff and residents have a chance to enjoy each other’s company.’ Parkhouse Grange Page 21 Standard 13 (13.1 – 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users’ preferences. 3 Key findings/Evidence Standard met? The Registered Manager said that visitors are welcome at the home at any time. Staff provide refreshments for visitors who are also welcome to share meals with service users. She said that at present approximately half the service users in the home have regular visitors. She said some of those visitors have befriended service users without visitors. Visitors see service users in their bedrooms or in one of the home’s four lounges. Standard 14 (14.1 – 14.5) The registered person conducts the home so as to maximise service users’ capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? The home has a relaxed routine and service users can get up and go to bed when they want, and choose where to sit, and where to dine. Most service users have their meals in the dining room but three have them in their rooms by choice. At present getting up times range from 5am to 8.30am and bedtimes from 6pm to 11pm. The Registered Manager said a couple of service users tend to wake up in the night and get up. She said ‘Waking at night is a feature of dementia. We encourage service users to sleep at night, but we can’t make them. Those that get up In the night like to potter round the lounges, have snacks, and sit and talk to the night staff.’ The home has links with Age Concern, and advocacy services can be requested through this organisation. Parkhouse Grange Page 22 Standard 15 (15.1 – 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The home has two part-time cooks and three kitchen assistants. The menu, which is on a six-week rota, showed a balanced and wholesome diet being offered with fresh vegetables daily. There are at least two choices of main course at every meal and a range of standard alternatives. Meals are served at the following times: Breakfast 8.30am Lunch 12.30pm Dinner 5pm Supper 9.30pm Lunchtime was observed. Service users were sitting at small tables, with co-ordinated tablecloths and serviettes, and fresh flowers. The menu was displayed next to the serving hatch. The meal consisted of a soup starter, followed by sausage casserole, or lamb and leek stew, with gravy, mashed potatoes, and peas. Dessert was chocolate sponge with custard. Service users’ comments about the meals included: ‘Good food.’ ‘Lovely food – I like the puddings.’ ‘There’s more food than we can eat.’ ‘The food is more appetising than I’ve had in other homes.’ Parkhouse Grange Page 23 Complaints and Protection The intended outcomes for the following set of standards are: • • • 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. Standard 16 (16.1 – 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence X X X X X X X 0 Standard met? This Standard was inspected at the last inspection on 4.05.04. Standard 17 (17.1 – 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Parkhouse Grange Page 24 Standard 18 (18.1 – 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Standard met? X X 0 This Standard was inspected at the last inspection on 4.05.04. Parkhouse Grange Page 25 Environment The intended outcomes for the following set of standards are: • • • • • • • • 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. Standard 19 (19.1 – 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users’ individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. However the following requirement remains outstanding: At present there is no secure area of the gardens suitable for service users who wander. The Registered Person agreed to create one when they applied last year to increase the number of dementia beds at the home. It is therefore disappointing that the garden remains unusable for service users who wander unless they are accompanied. The work must now be done as a matter of urgency. See Requirement 1 Standard 20. (20.1 – 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users’ private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Parkhouse Grange Page 26 Standard 21 (21.1 – 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Standard 22 (22.1 – 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Parkhouse Grange Page 27 Standard 23 (23.1 – 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence YES NO NO X X X X Standard met? 0 0 0 0 0 0 0 This Standard was inspected at the last inspection on 4.05.04. Parkhouse Grange Page 28 Standard 24 (24.1 – 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Standard 25 (25.1 – 25 8) The heating, lighting, water supply and ventilation of service users’ accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Standard 26 (26.1 – 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Parkhouse Grange Page 29 Staffing The intended outcomes for the following set of standards are: • • • • 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. Standard 27 (27.1 – 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 5 0 0 needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 13 3 410 No. staff hours allocated No. staff hours allocated No. of staff hours provided 0 0 448 0 0 0 0 18 11 Standard met? 3 Parkhouse Grange Page 30 The present staff team consists of the Registered Manager, the Deputy, four seniors, seven day carers, and five night carers. There are two cooks, three kitchen assistants, five cleaners and a part time handyman. At present the laundry assistant ‘s post is vacant so care staff are temporarily responsible for the laundry. There are four carers on duty on the morning shift, four on the afternoon shift, and two (waking) at night. The Registered Manager said as that as the home employs ancillary staff the care staff have more time to spend on service user care. At the last inspection concerns were raised by service users and visitors about the number of staff on duty and about staff attitudes. The Registered Manager has addressed these concerns. At this inspection staffing hours were found to exceed the minimum number recommended by the Residential Forum. Staff attitudes were found to be good. Staff were welcoming, enthusiastic about their work in the home, and appeared to have excellent relationships with service users. The Registered Manager said the current staff team is established and stable. One member of staff said ‘I love working here.’ All service users interviewed made positive comments about the staff including, ‘Everyone’s here to help me and make me happy’, and ‘The staff look after me.’ Standard 28 (28.1 – 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence X X Standard met? 0 This Standard was inspected at the last inspection on 4.05.04. Parkhouse Grange Page 31 Standard 29 (29.1 – 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? Records showed that all staff are subject to CRB (Criminal Record Bureau) checks. The Registered Manager said staff awaiting clearance sign a criminal declaration, supply references and are supervised at all times. The home has made the General Social Care Council’s codes of conduct available to staff and the Manager said they will be included in the next edition of their Employee’s Handbook. At the last inspection it was found that not all staff files contained photographs of the staff in question. A requirement was made for this to be rectified. This requirement has still not been met. The Registered Person must ensure that all staff files contain photographs, as stated in Schedule 2(1) of the Care Homes Regulations 2001 (which are enforceable). Continued failure to comply may result in regulatory action being taken against the Registered Person. See Requirement 2 Standard 30 (30.1 – 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Parkhouse Grange Page 32 Management and Administration The intended outcomes for the following set of standards are: • • • • • • • • 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. Standard 31 (31.1 – 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Standard 32 (32.1 – 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Standard 33 (33.1 – 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Parkhouse Grange Page 33 Standard 34 (34.1 – 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Standard 35 (35.1 – 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Standard met? 0 X X X This Standard was inspected at the last inspection on 4.05.04. Standard 36 (36.1 – 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Parkhouse Grange Page 34 Standard 37 (37.1 – 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? This Standard was inspected at the last inspection on 4.05.04. Standard 38 (38.1 – 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? At the last inspection some radiators in communal areas were found to be hot to the touch and to present risk to service users. The Registered Manager said following the inspection, and in response to the finding, a qualified person checked the boiler and the overall temperature turned down. At this inspection radiators were checked and fond to be warm, but not hot, to the touch. The home’s Fire Officer last inspected fire safety in the home on 10.01.05. A recommendation was made that the Fire Risk Assessment should be amended. The Registered Manager said this has been done. In a letter dated 9.03.05 the home’s Environmental Health Officer has asked ALA Care Ltd to improve and amend it’s corporate Health and Safety Policy. The Registered Manager said this is in the process of being done and the final document will be shown to the EHO for approval. Parkhouse Grange Page 35 PART C (where applicable) Condition COMPLIANCE WITH CONDITIONS Compliance YES No one under the age of 55years may be admitted into the home in categories MD or PD. Comments Condition • • • Compliance YES Service User numbers - No person falling within categories MD/MD(E) may be admitted to the home when there are 10 persons in total in these categories/combined categories already accommodated in the home. Service User numbers – No person falling within the category DE/E may be admitted to the home when there are 20 persons of that category already accommodated in the home Service user numbers - No person falling within categories PD, PD(E) may be admitted to the home when there are 5 persons of these categories/combined categories already accommodated in the home. Comments Condition Compliance YES To be able to admit a named person in the category Sensory Impairment (over 65 years of age) as identified in correspondence with CSCI dated 10.05.04. Comments Lead Inspector Second Inspector Kim Cowley Signature Signature Signature Regulation Manager Roger Bluff Date Public reports It should be noted that all CSCI inspection reports are public documents. Parkhouse Grange Page 36 PART D D.1 PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTS Registered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection. We would welcome comments on the content of this report relating to the Inspection conducted on 8 March 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Parkhouse Grange Page 37 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NO Comments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate NO NO NO Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 3 May 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YES D.2 Action plan was received at the point of publication YES Action plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan YES NO NO Other: enter details here NO Parkhouse Grange Page 38 D.3 PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies. D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable. Parkhouse Grange Page 39 Parkhouse Grange / 8th March 2005 Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.uk S0000001679.V205670.R01 © This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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!