Inspection on 18/11/05 for Parklands

This inspection was carried out on 18th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Parklands 24/01/08

Parklands 21/02/07

Parklands 16/03/06

Parklands 04/02/05

Parklands 23/09/04

Parklands 16/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Parklands Callow Hill Lane Callow Hill Redditch Worcestershire B97 5PU Lead Inspector N Andrews Unannounced Inspection 01:45 18 and 25 November 2005 th th 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 Parklands DS0000033906.V267531.R02.S.doc Version 5.0 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. Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Parklands Address Callow Hill Lane Callow Hill Redditch Worcestershire B97 5PU 01527 544581 01527 544393 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 Steven Sadhra Mrs Margaret Phillips Care Home 31 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (13), of places Physical disability over 65 years of age (12) Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th February 2005 Brief Description of the Service: Parklands is a large, detached property situated in a secluded, rural setting on the outskirts of Redditch overlooking the Worcestershire countryside. The property stands in several acres of ground surrounded by lawns and woodlands. There are car-parking facilities at the front of the premises. The property has been adapted for its current purpose as a residential care home providing personal care for a maximum of 31 older people i.e. people above the age of 65 years. However, it was operating as a 29-bed home on the day of the inspection. The home may also accommodate 12 older people with a physical disability and 6 older people with a dementia illness. The service users are accommodated on the ground, first and second floor of the premises in 7 double bedrooms and 17 single bedrooms. Five of the 7 double bedrooms have an en suite facility. One of the double bedrooms is currently used as a single bedroom. At the time of the inspection the home was accommodating 22 service users and there were 9 vacancies. The home has a passenger lift to assist the service users to gain access to the accommodation above ground floor level. The home’s main aim is ‘to provide a high standard of care for elderly people based on individual needs in a homely and comfortable atmosphere’. The home endeavours to ensure that the service users ‘retain their self-respect, individuality, privacy and independence’. The home has been operating under the present proprietorship for the past three years. Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one and a half days. The inspection included a tour of the premises. Time was spent with the registered manager assessing the progress made by the home in implementing the requirements and recommendation arising from the previous inspection. Some of the service users’ records were inspected and individual discussions were held with two service users and two members of staff. A brief discussion was also held with the registered provider. The home was inspected against twelve of the National Minimum Standards. Seven of the twelve Standards that were inspected were met, four were nearly met and only one was not met. The two service users with whom discussions were held spoke positively about the home and the standard of care that they received. Both service users felt confident about raising any concerns with the staff. They both felt that any concerns that might arise would be taken seriously and responded to quickly and appropriately. One service user stated ‘You feel safe in saying something’. One service user was satisfied with the level of activities provided but expressed regret that only four service users had ‘made the effort to go on a recent trip to Webb’s Garden Centre in Bromsgrove’. One of the service users described the staff as ‘very nice’ and confirmed that they respected the service users’ privacy. The same service user said ‘I’m happy here. I think the home is very good’. The other service user also spoke positively about the staff and said ‘The staff are very respectful. They’ll do anything for you. They’re very good on privacy. They will let you sit on your own if you want to but if you want something done you’ve only got to ask. I can’t praise the staff too highly. I enjoy being here, very much so, I really do’. One service user did not feel that there were sufficient activities at present. Separate discussions were held with two members of staff. One of the staff was a senior care assistant and the other member of staff was the cook. Both members of staff spoke positively about the home. It was confirmed that there was a ‘good team spirit’ amongst the staff that worked at the home and that good relationships existed between the staff and the service users. It was also stated that staff meetings were held approximately every ‘three to four months’. The cook said that she was aware of the service users’ food preferences and that she always sat and talked to the service users when they were admitted to the home. It was stated that, in order to cater for the dietary preferences of the service users, up to four different main meals could be provided on any particular day. It was confirmed that the kitchen contained all of the necessary equipment that was maintained in proper working order to enable the catering staff to provide meals of a high quality. It was pleasing to note the evident commitment of both members of staff to providing high standards. A suggestion was made that two of the ground floor toilets should Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 6 be converted into one larger toilet for the benefit of both the service users and staff. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 7 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 Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 The home provided clear and relevant information to enable prospective service users to make an informed choice about admission. However, the contents of the statement of purpose and the service users’ guide needed to be improved. The care needs of prospective service users were assessed by staff using an appropriate assessment form. EVIDENCE: A copy of the home’s statement of purpose was made available for inspection. The statement of purpose contained clear and relevant information. However, the copy that was provided did not include the final two sections i.e. sections 19 and 20. The statement of purpose also needed to be improved by the inclusion of • the address of the registered provider and registered manager, • a statement that the home is not registered to provide nursing care, • details of the arrangements made for consultation with service users about the operation of the care home e.g. service users’ meetings and the use of surveys/questionnaires, • details (in section 12) of the range of activities provided by the home and, Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 9 details (in section 13) of the emergency procedures to be followed in the event of a temporary closure of the home. In addition, the out of date reference in section 6 to the Registered Homes Act 1984 should be deleted and replaced by an appropriate reference to the Care Standards Act 2000. Similarly, the out of date reference in section 13 to notifying the ‘County Inspectorate within 24 hours’ should be deleted and replaced by an appropriate reference to giving ‘notice to the Commission for Social Care Inspection (CSCI) without delay’. A copy of the home’s service users’ guide was also made available for inspection. The service users’ guide contained clear and relevant information. However, the service users’ guide needed to be improved by the inclusion of • a standard form of contract for the provision of services and facilities by the registered provider to service users, • the physical environment standards met by the home in relation to the standards referred to in Standard 1.1, • a description of the individual accommodation and communal space provided, • details of the relevant qualifications and experience of the registered provider, manager and staff and • service users’ views of the home. In addition, the out of date reference on page 6 to the ‘regional NCSC’ should be deleted and replaced by an appropriate reference to the local office of the CSCI. A copy of the assessment form used by the home for assessing the needs of prospective service users was made available for inspection. The registered manager said that the assessment form had been developed recently into its present format. The assessment form contained a reference to all of the issues listed in Standard 3.3. It was confirmed that all of the service users had been assessed. The registered manager stated that the new assessment form had been used to assess the service users that had recently been admitted to the home. It was the registered manager’s intention to continue to use the new form for assessing all prospective service users. It was confirmed that all of the service users had a plan of care. • Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10 The home was making steady progress in the development of the service users’ care plans. However, there was scope for further improvement. There was evidence to show that the service users’ privacy and dignity was respected. EVIDENCE: It was confirmed that all of the service users had a care plan. It was also confirmed that the care plans were reviewed every month and that the service users and their relatives were involved in the reviews. The registered manager stated that a new format had been developed for the service users’ care plans. The new care plans had been used in respect of the four service users that had been most recently admitted to the home. It was also stated that the staff were in the process of changing all of the service users’ care plans into the new format. It was intended to complete this process by 31 March 2006 and, at the same time, develop the home’s key worker system. The home’s response to the requirement that was made in regard to the service users’ care plans as a result of the previous inspection was assessed. The requirement was that service users’ plans used by the home must be completed thoroughly and include all areas of the service users’ lives. A copy of the care plan used by the home was made available for inspection. The care plan included a reference to all of the aspects of care listed in Standard 3.3 except for a Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 11 specific reference to weight. The term ‘absconding’ in section 6 of the care plan is not felt to be an appropriate word to describe service users that become missing from the home. Apart from these two issues the requirement was regarded as having been implemented. Copies of the service users’ care plans were examined. It was noted that the details of the action to be taken by the staff to meet the needs of the service users needed to be more specific. It was also noted that one service user who had had a fall had not undergone a risk assessment. The home’s response to the requirement that was made in regard to Standard 8 as a result of the previous inspection was assessed. The requirement was that risk assessments for the use of bed-rails must be carried out. The registered manager confirmed that risk assessments in respect of the four service users who required the use of bed-rails had been carried out and recorded. The requirement had, therefore, been implemented. The registered manager confirmed that the staff endeavoured to respect the service users’ privacy and dignity at all times in regard to the various aspects of their personal care. In addition to the telephone that was located in the main hallway, the home had a mobile handset that the service users were able to use in the privacy of their own rooms. Three service users had a telephone in their bedrooms. The registered manager confirmed that fixed screening (curtains) was provided in all of the double bedrooms. It was confirmed that other aspects of Standard 10 were also met. Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 and 15 The service users were able to receive their visitors at any reasonable time and in private and were encouraged to maintain their independence. The service users received a wholesome, nutritious and varied diet in accordance with their preferences and needs. EVIDENCE: The home’s response to the requirement that was made in regard to Standard 12 as a result of the previous inspection was assessed. The requirement was that a record of activities undertaken by service users must be kept. The registered manager confirmed that a record of the activities in which the service users had participated was maintained in their individual files. Therefore, the requirement had been implemented. However, it was suggested that a separate daily record of the social/leisure activities provided by the home and the names of the service users that were involved would be beneficial. A separate daily record would help to ensure a varied programme of activities and to identify the service users whose participation in such activities needed to be encouraged. The registered manager stated that she would introduce a folder in which a record of activities could be kept. The service users were able to receive their visitors at any reasonable time and in private. No unnecessary restrictions were imposed in regard to visiting. The registered manager confirmed that the service users’ right to choose whom they saw or did not see was respected. The service users’ guide Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 13 contained a reference to the home’s policy on maintaining relatives and friends’ involvement with service users. The registered manager expanded the information provided in the service users’ guide in order to emphasise the importance of this aspect of the service users’ care. There was involvement in the home by one local community group in the form of visitors from Feckenham Church who came to the home every week to talk with the service users. The church members had been coming to the home regularly for a considerable period of time and their visits were welcomed and appreciated. The registered manager confirmed that the service users and/or their relatives maintained responsibility for the service users’ finances. It was also confirmed that no one connected with the running of the home acted as an agent or appointee on behalf of any of the service users’ in regard to their financial benefits etc. However, the home did handle the money that was handed over for safekeeping in respect of eighteen of the current service users. The money was used for the service users’ personal expenses e.g. hairdressing, and was kept in individual plastic envelopes in a secure storage facility. The home maintained individual accounts of all of the financial transactions and receipts were issued. The financial records were checked and were up to date and accurate. The registered manager confirmed that none of the service users required the help of an advocate at the present time. However, it was stated that the advocacy service had been used in the past. A reference to the advocacy service and the telephone number were included in the service users’ guide. The registered manager stated that the service users were entitled to bring pictures and other small items of furniture with them when they were admitted to the home. During the inspection some of the service users’ bedrooms were inspected and it was noted that the majority had been personalised. However, it was also noted that the service users’ guide did not include a statement confirming the service users’ right of access under the Data Protection Act 1998 to the records and information held about them by the home. The service users were offered three full meals each day. Breakfast was usually served between 8:00 am and 10:00 am. The service users ate breakfast in their own bedrooms if they wished to do so. Lunch was normally served between 12:30 pm and 1:00 pm. The service users ate lunch in the dining room or in the lounge if they preferred. The teatime meal was served at 4:15 pm and this was also eaten in the dining room or lounge. The registered manager gave an assurance that the teatime meal was served early in accordance with the service users’ wishes and not for the convenience of the home’s routines. Supper was served between 6:30 pm and 7:00 pm and again at 9:00 pm. The registered manager said that supper consisted of drinks and snacks e.g. toast, biscuits, cakes or sandwiches etc. Drinks were also provided mid-morning and mid-afternoon. The cook confirmed that four service users had their meals liquidised and two service users had their food cut into small pieces. The registered manager stated that one service user was at risk of choking and was, therefore, fed every meal by a member of staff. The Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 14 registered manager stated that a risk assessment had not been carried out in respect of the service user. However, it was stated that a ‘thickener’ was added to the service users’ drinks to enable her to swallow more easily. The registered manager stated that a total of four service users needed to be fed by staff. It was confirmed that special diets were provided for three service users who were diabetics. The registered manager stated that a nutritional assessment was being carried out on all of the service users using the Worcestershire Malnutrition Universal Screening Tool. It was stated that this process would be completed by 31 March 2006. None of the service users required any special equipment or eating aids apart from one service user who used a plate with a plastic lip. The record of the food provided showed that the service users were provided with a varied and nutritious diet. One of the two service users with whom discussions were held described the food as ‘Very generous, good variety and a very good standard’. The other service user stated ‘The food is excellent, we have a very good cook’. It was also confirmed that an alternative meal was provided to the service users if they did not like the meal that was offered. Parklands DS0000033906.V267531.R02.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home had a satisfactory complaints procedure. The service users were confident that their complaints would be listened to and dealt with appropriately. EVIDENCE: The home had a satisfactory complaints procedure that was referred to in both the statement of purpose and the service users’ guide. A record of the complaints made against the home was maintained. One complaint had been made against the home during the previous year. The complaint had been received by the CSCI and was in the process of being dealt with by the CSCI at the time of the inspection. The registered manager had investigated the complaint thoroughly and had provided detailed information and documentation as part of the home’s response. The two service users with whom discussions were held during the inspection stated that they felt confident about referring any concerns that might arise to the staff. They also stated that they felt confident that any complaint that they made would be taken seriously and responded to quickly and appropriately. Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The service users’ bedrooms were comfortable, homely and well decorated. However, improvements to the facilities in some of the bedrooms were needed. EVIDENCE: The home’s response to the requirement that was made in regard to Standard 19 as a result of the previous inspection was assessed. The requirement was that all radiators must be covered or thermostatically controlled. The registered manager confirmed that the radiators in all of the service users’ bedrooms and in the corridors had been provided with protective guards. It was also confirmed that the other radiators that had not been covered were all thermostatically controlled. The requirement was, therefore, regarded as having been implemented. The home’s response to the recommendation that was made in regard to Standard 22 as a result of the previous inspection was assessed. The recommendation was that an assessment should be carried out as necessary by an occupational therapist for service users with sensory impairments. The recommendation had not been implemented and still stands. Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 17 The majority of the service users’ bedrooms on the first and second floor were inspected in order to assess the home’s response to the two requirements that were made in regard to Standard 24 as a result of the previous inspection. The first requirement was that all of the items of furniture specified in Standard 24.2 must be provided in rooms occupied by service users. It was pleasing to note that the bedrooms had been personalised and were comfortably furnished and decorated. However, it was also noted that not all of the items listed in Standard 24.2 had been provided in all of the bedrooms. In particular, bedrooms 21 and 22 did not contain comfortable seating for two people, bedrooms 7, 8, and 18 did not contain two accessible double electric sockets and bedrooms 7, 8, 10, 11, 14, 16, 21 and 25 did not contain a table to sit at. The requirement, therefore, had not been implemented and still stands. The registered manager was advised to carry out a full audit of the contents of all the service users’ bedrooms to ensure that all of the items listed in Standard 24.2 were provided. The second requirement was that door locks that meet the recommended specification must be provided for all service users’ bedroom doors. The requirement had not been implemented and still stands. During the inspection of the service users’ bedrooms it was also noted that the carpet in bedroom 20 was worn and, as a consequence, presented a possible safety hazard. The staff alarm call system in bedroom 7 was also not in working order. The registered manager was required to take immediate action to address both of these issues. During the inspection of the service users’ bedrooms it was also noted that the temperature of the hot water issuing from the wash hand basins in some of the bedrooms was above an acceptable level. The temperature of the hot water in several bedrooms was tested and the following temperatures were recorded; bedroom 7-51 degrees C, bedroom 11-45.5 degrees C, bedroom 16-49.3 degrees C, bedroom 18-48 degrees C and bedroom 23-49.8 degrees C. The registered manager was required to take immediate action to address this issue. It was also noted that the hot water outlets in bedrooms 16 and 23 had not been fitted with thermostatically controlled mixer valves. Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 28 The home employed sufficient staff with appropriate skills to meet the needs of the service users. The home is committed to NVQ training. EVIDENCE: A list of all the staff employed to work at the home was made available for inspection. In addition to the registered manager who was employed to work 40 hours per week, the home also employed a deputy manager for 32 hours per week, a team leader for 40 hours per week and 14 care staff to cover daytime and night-time duty for a total of 424 hours per week. The deputy manager was on long-term sickness leave and, therefore, the team leader was covering the post of deputy manager. The home also employed a part-time administrative assistant, catering and maintenance staff. The cook was employed to work 6 days a week for a total of 48 hours. The cook was helped by an assistant cook who worked 28 hours per week and another member of staff who worked in the kitchen two days a week. Two domestic staff were employed for a total of 56 hours per week. A housekeeper was employed for 32 hours per week to ensure that the laundry service was maintained. A copy of the staff rota for the two weeks ending 24 November and 1 December 2005 was made available for inspection. The staff rota indicated that adequate numbers of staff were employed during the day and that two waking staff were on duty at all times during the night. The registered manager confirmed that, when the number of service users was greater than at present, the number of staff on waking duty at night was increased to three. The registered manager also said that usually three care staff were on duty in the mornings in addition to the registered manager or senior member of staff. Two care staff and a senior member of staff were on duty in the evenings. Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 19 Seven members of the care staff had undertaken NVQ level 2 training. Therefore, the home was well on its way to meeting the expected target of 50 trained members of care staff (NVQ level 2). However, the target had not yet been achieved. The registered manager stated that one member of staff was currently undertaking NVQ level 2 training. Agency staff were not used and none of the staff were below the age of 21 years. Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 The home was managed by a competent, and experienced person who was committed to the provision of a high standard of care. EVIDENCE: The registered manager was competent and experienced and had worked at the home for approximately 20 years. The registered manager had occupied her current post for approximately 15 years. The staff with whom discussions were held described the registered manager as ‘very fair, approachable and supportive’. The registered manager was undertaking the Registered Managers’ Award (RMA) training. She hoped to complete the training by 31 December 2005. Following the successful completion of the RMA training, the registered manager intended to complete the necessary units in order to achieve the NVQ level 4. In addition, the registered manager was currently undertaking training in conflict management. The registered manager had also undertaken training in the protection of vulnerable adults from abuse (21/01/05), fire safety (16/02/05) and dementia awareness (09/05/05). The registered manager had undertaken infection control training in 2003 and Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 21 moving and handling training and safe handling of medication training in 2004. However, the registered manager acknowledged that her first aid training certificate was out of date and that training in risk assessment also needed to be completed. A copy of the registered manager’s job description was made available for inspection. The job description was satisfactory. The home’s response to the requirement that was made in regard to Standard 33 as a result of the previous inspection was assessed. The requirement was that a quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. The registered manager confirmed that the home’s quality assurance system consisted of some of the views of visitors obtained during February 2005, service user questionnaires (undated) used during February 2005, an admission questionnaire (not yet used) and an audit of the service users’ bedroom facilities. Further work needed to be carried out to improve and extend the quality assurance system. The system needed to be more comprehensive and more specific about the standards that are being measured. The requirement had not been fully implemented and still stands. The home’s response to the three requirements that were made in regard to Standard 38 as a result of the previous inspection was assessed. The first requirement was that where service users wish to have their bedroom doors open, a fire safety risk assessment must be carried out and an automatic closing device provided. The registered manager stated that the service user to whom this requirement was applicable had left the home and was now living in the community. It was confirmed that there were no other service users to whom the requirement applied. Therefore, the requirement, which was no longer regarded as relevant, has been deleted. The second requirement was that emergency lighting tests must be carried out at the required frequency. The third requirement was that weekly fire safety checks must be carried out and recorded. The home’s fire safety records were inspected on the first day of the inspection. It was noted with concern that there was no recent record of the emergency lighting tests and that there were gaps in the record of the weekly fire alarm tests. Consequently, a notice of immediate requirement in respect of both of these matters was issued to the registered manager. The following week, during the second day of the inspection, the fire safety records were inspected again. It was pleasing to note that the two fire safety matters that had been the subject of the notice of immediate requirement had been satisfactorily addressed. The registered manager stated that the emergency lighting had been checked in August 2005. It was confirmed that a contractor was carrying out electrical work that would result in an upgrade of the home’s emergency lighting system. It was also confirmed that the home’s emergency lighting had been tested except for the ground floor. The registered manager stated that the ground floor emergency lighting would be tested in approximately two weeks when the outstanding work on the faulty electrical fittings had been completed. The registered Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 22 manager gave an assurance that all the fire safety checks/tests would continue to be conducted and recorded at the frequency recommended by the Fire Safety Officer. Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 23 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X 1 X X STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X X Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP1 Regulation 4 Requirement The statement of purpose must be amended in accordance with the guidance given in this report so that it includes all of the information detailed in Regulation 4 and Schedule 1. The service users’ guide must be amended in accordance with the guidance given in this report so that it includes all of the information detailed in Regulation 5 and Standard 1. Copies of the service users’ guide must be given to all current, and any prospective, service users. The service users’ care plans must set out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service users are met. A risk assessment must be carried out and recorded in respect of all the service users at risk of falling. A risk assessment must be carried out and recorded in DS0000033906.V267531.R02.S.doc Timescale for action 31/01/06 2 OP1 5 31/01/06 3 OP7 15 31/01/06 4 OP7 15 31/12/05 5 OP15 13,15 31/12/05 Parklands Version 5.0 Page 25 6 OP15 13,15 7 OP24 16 8 OP24 12,23 9 OP24 13,16 10 OP24 13,23 11 OP25 13,23 12 OP25 13,23 respect of all service users who are at risk of choking. The process of carrying out a nutritional assessment in respect of all the service users must be completed. All of the items of furniture specified in Standard 24.2 must be provided in rooms occupied by service users. If the provision of any item poses an unacceptable risk to the service user or they decline the provision, details of the discussions and decision about this should be recorded in the assessment of the service user’s needs and written into their contract. (Previous timescale of 28/02/05 not met). Door locks that meet the recommended specification must be provided for all of the service users bedroom doors. (Previous timescale of 28/02/05 not met). The carpet in bedroom 20 must be replaced in the near future and, in the meantime, the area that is worn/joined must be taped or covered in order to prevent any possible accidents. The staff alarm call system in bedroom 7 must be repaired and maintained in proper working order. The temperature of the hot water in all of the service users’ bedrooms and in all of the hot water outlets used by service users must be tested, regulated where necessary, and maintained at 43 degrees C in order to prevent the risk of scalding. Thermostatically controlled mixer valves must be fitted to all of the hot water outlets used by service users in order to prevent the risk DS0000033906.V267531.R02.S.doc 31/03/06 31/12/05 31/12/05 25/11/05 25/11/05 25/11/05 02/12/05 Parklands Version 5.0 Page 26 13 14 OP31 OP33 9,18 24 of scalding. The registered manager must undertake training in first aid at work and in risk assessment. A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 33. (Previous timescale of 28/02/05 not met). 31/03/06 31/03/06 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 2 Refer to Standard OP7 OP7 Good Practice Recommendations The service users’ care plans should include a reference to the service users’ weight and the term ‘absconding’ should be deleted in favour of a more appropriate term. The process of changing all of the service users’ care plans to the new format and the development of the home’s key worker system should be completed within the timescale set by the registered manager. A daily record of the social/leisure programme of activities arranged or provided by or on behalf of the home should be maintained. A statement confirming the service users’ right of access under the Data protection Act to the records and information held about them by the home should be included in the service users’ guide. An assessment should be carried out as necessary by an occupational therapist for service users with sensory impairments. Arrangements should be made for staff to receive training that will enable a minimum of 50 of the care staff to attain a qualification at NVQ level 2 or equivalent by 2006. The registered manager should pursue the training necessary to achieve a qualification at NVQ level 4 in management and care by 2006. 3 4 OP12 OP14 5 6 7 OP22 OP28 OP31 Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Parklands DS0000033906.V267531.R02.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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