Inspection on 07/06/05 for Parkwood House

This inspection was carried out on 7th June 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 no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Parkwood House 06/08/07

Parkwood House 08/06/06

Parkwood House 18/11/05

Parkwood House 21/02/05

Parkwood House 29/12/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Parkwood House West Street Harrietsham Maidstone Kent ME17 1JZ Lead Inspector Ann Block Unannounced 07 June 2005 16:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Parkwood House Address West Street Harrietsham Maidstone Kent ME17 1JZ 01622 859710 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Counticare Limited CRH Care Home 13 Category(ies) of Learning disability (13) registration, with number Physical disability (3) of places Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three service users who have a physical disability also have a learning disability Date of last inspection 21 February 2005 Brief Description of the Service: Parkwood House is a home for younger adults with a learning or physical disability and is owned by Counticare. It is a detached property with extensive grounds, garden (incorporating a sensory garden) and car parking for several vehicles. Also on site adjacent to the main building is a separate small day care unit, which provides activities of a more educational nature. A further facility containing a range of soft furniture and aids for relaxation is also available for use by service users.The home is situated on the outskirts of Harrietsham village lying on the main Ashford to Maidstone road. Facilities such as shops etc are within walking distance. There is good access to bus services and a main line station is situated in the village itself. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Tuesday 7th June between 2.45 and 6.15pm. The Commission was represented by Regulatory Inspectors Ann Block and Gary Bartlett. The Acting Manager and Acting Area Manager were on site. The focus of the inspection was to establish current management arrangements and to assess action on requirements and recommendations made at previous inspections. Other areas of life for service users will be assessed at the next inspection. Due to the direction of this inspection and the nature of the service, this report includes very limited comment from service users or support workers. On this occasion, evidence was gained from observation, speaking with management and supporting records. The inspectors were very disappointed with the lack of progress on actions required and recommended at the last inspection, and in the awareness and understanding of management responsibilities. The overall quality of life for service users is restricted by lack of a sound management structure, staffing levels and facilities in the home. What the service does well: What has improved since the last inspection? Some information about the home is now available in symbol format making it easier for service users to understand. Care plans are being improved and made more accessible for daily use. The communication book now maintains client confidentiality. Work is underway to redecorate the home. The Fire Safety Officer has approved the fire risk assessment. Staff rosters are held which show both planned and actual hours worked. The acting manager has Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 6 reduced her rostered direct work with service users. A business plan for Counticare with input from Parkwood has been written. A greater range of policies and procedures relevant to the client group has been set up. All staff and each service user has a recent photograph on file. 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. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,4 & 5 Service users and others do not have accurate information about Parkwood House to enable them to make a judgement whether the home would be suitable for them. Service users security of placement is not well supported due to the terminology of the contract between themselves and Counticare. EVIDENCE: A printed symbol and text service users guide has been designed which makes information more accessible to service users likely to be accommodated. The service users guide now includes a form of contract but does not contain accurate detail of the service, for example it does not mention that access around the home for wheelchair users is restricted. The statement of purpose remains incomplete and inaccurate. Each service user has a contract between the provider and themselves. The contract between Counticare and the service user remains inaccurate in that it clearly states that: ‘You will not be discriminated against in relation to your sex, age or disability and you will be supported to have tour needs met in all these areas.’ Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 9 Again, the contract filed in a service users file did not have the stated attachments in place. The contract is not in a format which can be understood by service users. Previous inspections have identified that there is provision for service users and family to visit the home before admission, meet other service users and stay for a meal. The acting manager stated that the organisational placements officer remained the person who would assess any prospective service users although she believed she might be more involved in the process. As no new service users have been admitted this was not evidenced in practice. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,9, 10 Service users care needs will be more reliably known by improved use of care plans. Service users do not have ready access to monies held on their behalf. EVIDENCE: The acting manager stated that work is underway to reformat care plans and risk assessments and to make them more accessible on a day-to-day basis. How this works in practice will be assessed at the next inspection. The acting manager said that monies were still held in a single account managed from the Head Office. Within that account service users were named. Small amounts of money are held securely at the home, larger amounts must be requested through Head Office and countersigned by a Director. This leads to a delay in the monies being received by the service user. The communication book is now used more appropriately and recent entries ensure that confidentiality is maintained. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 & 16 Service users have their social and nutritional needs well met. Choice would be improved by freedom of movement for all service users. EVIDENCE: Parkwood House has its own separate annex which can be used for day and evening activities. Use is made of Counticare day services in Folkestone. A driver/support worker is appointed who uses Counticare transport based at the home to take service users to day services. Those staff who are able and willing to drive may use additional Counticare transport based at Parkwood. The manager considers that she has extended activities for service users including use of facilities in the local area. At previous inspections it was identified that there is good contact with families who are encouraged to be involved with the service users. Policy states that visitors are welcomed at all times. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 12 Service users who require a wheelchair to mobilize are significantly restricted in freedom of movement in Parkwood. Areas inaccessible by wheelchair users include the secondary lounge area leading off the main lounge, one fire exit on the ground floor and rooms on the upper floor. Access is difficult to the conservatory and activities/snoozelem annex. There is ramped access to the front door and from the patio to the main lounge. One service user has an electric wheelchair which he cannot use indoors due to the width of doorways etc. A cook is appointed who was reported as having excellent relationships with service users, including encouraging them to assist in meal preparation. At the time of inspection the main meal was individually plated Thai green chicken curry. One meal was taken outside to a service user who wished to remain in the forecourt area. Wooden picnic bench/table units are sited there. A dining room offers basic provision for mealtimes. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not assessed EVIDENCE: Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 Service users and others have systems by which they can complain however the systems lack structure and consistency. EVIDENCE: There is a lack of consistency in the complaint procedures. A number of differing versions are provided, each being worded slightly differently. The procedure seen on display in the office held contact details for the Commission, the one in the policy folder did not state that the Commission could be contacted at any time, the policy in the revised service users guide gave correct details. The complaint file is not being used appropriately. The folder held documents regarding recent staff disciplinary issues and incidental management paperwork in addition to complaint material. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29 & 30 The environment cannot be considered wholly suitable for the service users currently accommodated. EVIDENCE: Parkwood House was originally privately owned and some décor reflects this earlier ownership, not being entirely suitable for the current client group. Work in underway to redecorate the home with some bedrooms and hallways freshly painted. The cleaner had been on leave for the previous week, this was reflected in the lack of attention to detail. Support workers had carried out essential cleaning. There is no lift, hence those with mobility difficulties cannot access the upper floor. Privacy is significantly compromised by the continued use of shared rooms. Two shared rooms are currently being used for single occupancy. The acting manager said it had been agreed that one of these would remain for single occupancy whilst the current person resided there. There was no indication that the other first floor shared room would remain for single occupancy Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 16 although the service user residing there said she liked having the room to herself. A single room is vacant. Service users should be able to make a positive informed choice to share, and if consenting, with whom, or be offered the opportunity of moving to a single room. The layout of shared rooms, in particular the positioning of the washbasin and door, cannot guarantee privacy. As detailed in part in the last inspection report the following were again noted in shared rooms: • Two TV’s in a shared room – begging the question of differing wishes regarding viewing. Staff considered that the two occupants usually watched one TV or one went into the lounge and watched it there. Entry through the one persons part of the room to gain access to the other part of the room and to the washbasin Insufficient room in one of the shared rooms for use by the occupying wheelchair users. A mobile screen in situ. The screen was unstable both when folded and when opened and constituted a risk, particularly as both occupants of the room are wheelchair users. Inadequate positioning of artificial lighting to ensure both occupants received sufficient light. Restricted use of a room to give personal care, as privacy could not be maintained. • • • • • Leading from the main house is an indoor swimming pool which can also be used by service users from other Counticare services. Rooms have two or three locks on, one a star lock, one a Yale type crash lock and one a standard lock. Reference was made at a previous inspection to a card lock also being in use. Toilets and bathrooms are lockable. Service users do not have access to a phone which can be used in private. There is a wet shower room and bathroom on the ground floor, a standard bathroom and a double sized Jacuzzi bathroom on the first floor. The Jacuzzi bathroom layout and facilities remain from the previous private occupancy and are more suitable for a family environment. There are separate toilets for swimming pool and staff use and one close to the communal areas. The lounge is large and leads to the lower lounge and conservatory. Settees and easy chairs are provided. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 17 Work has commenced to provide facilities for service users with additional needs, but provision still does not meet the stated aims of the service. The fire risk assessment has been sent to the Fire Safety Officer as recommended at the last inspection, with a positive response letter seen. The fire risk assessment had not been updated to include how service users who may not be compliant would be supported in the event of fire. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33 &34 Limitations in staff numbers and competencies reduce opportunities for a broad based good quality of life for service users. EVIDENCE: The acting area manager said that, in his view, staff morale had improved since recent senior staff changes. At the time of this inspection, this was not evidenced as staff were noticeably more reticent to enter into conversation with the inspectors than they had been on previous occasions. The management structure currently consists of a manager from another service who is piloting an area manager post and an acting manager who does not meet the standards required of a registered manager. The acting deputy manager recently resigned, the contracted deputy manager is acting as team leader pending appeal in respect of designated hours. There is a team leader vacancy, as one team leader transferred to another home within the organisation. There remains a significant use of agency and bank staff, particularly at weekends. Numerous comments were made regarding staff shortages. Recruitment had recently taken place on an organisational basis. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 19 Rosters are held of planned and actual hours. A staff on duty list was waiting to be completed in the entrance hallway. Staff files were comprehensive and contained a range of recruitment information. The acting manager was unable to evidence that Criminal Records Bureau checks had been carried out for all staff due to the lack of accurate records. She stated Head Office had advised her that POVA checks were adequate for staff to start work pending later application for a Criminal Records Bureau check. This is incorrect and presents a risk to service users. The acting manager stated that staff would be supervised until the Criminal Records Bureau check had been returned. It was later stated that one employee had been in a work situation where he had routinely been alone with service users, away from the home, without a Criminal Records Bureau check. The differences between POVA and Criminal Records Bureau checks were explained to the acting manager. There were records of issues about staff practices which the acting manager said were being dealt with by liaising with Head Office human resources. One warning letter was not available for inspection at the home as required by Regulation. The acting manager showed a lack of information and understanding as to the correct processes involved or accurate detail of the latest incident. Counticare have a training officer and a list of training offered was seen in the office. The training matrix on display was blank, it would therefore be very difficult to identify individual staff training that had been completed or was required from such a record. The manager did not offer an alternative staff training management tool, consequently actual training undertaken by staff was not assessed. The home is currently unlikely to meet the standard for 50 of staff to hold NVQ level 2 in care training by the end of 2005. A team leader spoke of a planned new induction training package which was being implemented. It was agreed that there might be some staff who have not had a comprehensive induction, including staff who had no previous care experience. A number of staff work very long hours with some 13 hour shifts. One person was recorded as having worked 198 hours over a 4 week period. Another person was recorded as routinely working 8 waking nights on and 8 off. The acting manager stated that staff preferred this work pattern, and one member of staff had refused to change her shift pattern. Staff complete a working time regulations exemption form and work additional hours to cover shift deficits. Comment has been made to the inspector that there is pressure to work additional hours. The acting manager disagreed with this, stating that vacant shifts were posted for staff to volunteer. The acting manager said that with the support of the acting area manager, she has reduced the time spent working ‘on the floor’. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,40,41 & 42 The management of the home is limited in its effectiveness. Service users safety is not reliably evidenced. EVIDENCE: The acting manager was appointed in autumn 2004, having had many years experience working with the client group. Since then she has shown her understanding of service users with learning difficulties and behaviours which might challenge, setting up behaviour management systems which have improved life for those service users involved. The acting manager does not meet the standards necessary for registration with the Commission. A company business plan with detail specific to Parkwood was seen in the office. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 21 Since the last inspection the acting manager has written a number of polices and procedures relevant to Parkwood. A few were signed, the majority were dated. The acting manager stated that each service user and each member of staff has a recent photograph. There is a large lawned area to the front of the property, partly secured by strong post and rail fencing. The steeply sloping area bordering the main road is not similarly secured and must be risk assessed and made safe. A small fenced sensory garden is provided. Access to the garden from the patio area is potentially by two sets of steps, one had a chain across, the other was partly secured by a large fibre glass object but would allow service users to walk round it. The acting manager and area manager consider environmental risk assessments have been carried out but unsure whether this was included. There was some confusion over the requirement for staff to attend fire drills and practices at regular intervals. The acting manager was unaware that training in fire awareness differed from fire drills, particularly where formal training had taken place elsewhere. The acting area manager believed that all staff had undertaken a recent fire drill but is to provide evidence of this to the Commission. A current employers liability certificate was seen. Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 x x 3 2 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 1 1 3 1 2 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 2 x Standard No 31 32 33 34 35 36 Score 1 1 1 1 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Parkwood House Score x x x x Standard No 37 38 39 40 41 42 43 Score 1 1 x 3 x 1 x H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1.1 & 2 Regulation 4 (1) 5 (1) Requirement The registered person shall compile in relation to the home a written statement of purpose which shall include a statement as to the matters listed in Schedule 1. The registered person shall provide a written guide to the care home which shall include the terms and conditions in respect of the accommodation to be provided for service users including as to the amount and method of payment of fees, a standard form of contract for the provision of services and facilities by the registered provider to service users, the most recent inspection report, a summary of the complaint procedure established under Regulation 22. The statement of purpose and service users guide must be consistent with the service provided and include clear detail of any restrictions to facilities This requirement is repeated from the inspection of 21 February 2005 The registered person shall not Timescale for action This must be completed by 31 August 2005 2. YA3.8 14 (1) A detailed Page 24 Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 provide accommodation to a service user at the care home unless following assessment the home is suitable for the purpose of meeting the service users needs in respect of his health and welfare. This was a requirement from the inspections of 25 March 2003, 15 May 2003, 29 December 2004 and 21 February 2005 3. YA16.8 YA18.1 YA24.9 YA29.1 23 (1) (2) The registered person must ensure that the physical design and layout of the premises to be used as the care home meet the needs of the service users. This will include that where persons who are wheelchair users are accommodated, there must be level or ramped access to those areas which are used or provided for use by service users in the home and suitable adaptations, aids and facilities to meet the needs of service users with disabilities. This will also include the phasing out of shared rooms, ensuring that service users in shared rooms have evidence that they have made a positive unbiased choice to share, that a shared room is suitable for the person being accommodated there and that a suitable single room has been offered. This was a requirement from the inspections of 25 March 2003, 15 May 2003, 29 December 2004 & 21 February 2005. The registered person must ensure that all parts of the home are reasonably decorated; this will include service users bedrooms. Work to redecorate bedrooms action plan as to how this will affect both existing and future service users must be sent to the Commssion by 31 July 2005 A detailed action plan as to how this will affect existing service users must be sent to the Commssion by 31 July 2005 4. YA24.12 23 (2) An action plan has been received Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 25 5. YA32.1 YA 33.1 18 (1) 6. YA34.3 19 (1) 7. YA39.1 24 (1) (2) (3) 8. YA41.1 17 (2) Schedule 4 and communal areas is being undertaken. There must be staff on duty in sufficient numbers who have the skills and knowledge to carry out the work they are to perform, this will include: A competent and effective senior team in place. All staff have received sound, comprehensive induction training Evidence must be available that all staff have a Criminal Records Bureau certificate with evidence that application was made before employment commenced in respect of all staff appointed after 7 June 2005. The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home The registered person shall supply to the Commission a report in respect of any review conducted by him for the purposes of the above paragraph and make a copy of the report available to service users. The system referred to in paragraph 1 shall provide for consultation with service users and their representatives. This requirement is repeated from the inspection of 21 February 2005 All records relating to staff, including disciplinary records, must be available for inspection in the home. This must be completed by 31 August 2005 This must be completed by 31 August 2005 A detailed action plan of how this will be carried out must be received by the Commissio n by 31 July 2005 9. YA42.2 23 (4) (e) The registered person must ensure, by means of fire drills This must be completed by 31 August 2005 and from thereafter Evidence that this Page 26 Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 10. YA 42.3 13 (4) and practices at suitable intervals, that the persons working at the care home, and so far as practicable service users, are aware of the procedure to be followed in case of fire. This will include all staff receiving drills or practices at not more than 6 monthly intervals for day staff and 3 monthly intervals for night staff. A risk assessment of the grounds must be carried out which identifies any areas of risk, action to be taken to reduce or remove the risk with timescales for such action to be completed. has been actioned in full must be sent to the Commissio n by 31 July 2005 The risk assessmen t must be received by the Commssion by 31 July 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA2.1 Good Practice Recommendations The manager of Parkwood should be provided with any information obtained in respect of pre admission assessments and fully involved in the admission of service users to Parkwood in line with her legal responsibilities. Not assessed Each service user should have a statement of terms and conditions as described under standard 5.2. Any such statement should be accurate and reflect current practice including specific detail of what fees cover. This recommendation is repeated from the inspection of 21 February 2005. Work to involve service users in the day to day running of the home should continue. Not assessed There should be evidence that staff respond promptly to risks when presented which includes completing a risk assessment where required. Not assessed H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 27 2. YA5.1 3. 4. YA8.1 YA9.2 Parkwood House 5. YA22.3 6. YA22.7 7. YA23.2 8. YA24.11 9. YA26.2 10. YA32.5 11. YA33.1 12. YA40.1 13. YA42.3 The complaint policy should ensure that it indicates that the Commission can be contacted at any stage in the process. This recommendation is repeated from the inspection of 21 February 2005 in respect of consistency of information. It is recommended that the format of storage and recording of complaints be reviewed to ensure all documentation relating to a complaint is accessible. From the inspection of 7 June 2005, this includes that such records should be specific to complaints This recommendation is repeated from the inspection of 21 February 2005. It is recommended that the home’s procedures for reporting suspicion or evidence of abuse or neglect be clarified. Not assessed Consideration should be given to including in the fire risk assessment those risks presented by service users who by choice or otherwise may not be compliant to the evacuation process. This recommendation is repeated from the inspection of 21 February 2005. Consideration should be given to providing a phone which can be used in private. This recommendation is repeated from the inspection of 21 February 2005. It is recommended that work should continue to ensure that a minimum of 50 of staff have achieved NVQ level 2 by 2005. This recommendation is repeated from the inspection of 25 March 2003, 15 May 2003, 23 October 2003, 29 December 2004 & 21 February 2005 It is recommended that staff rosters should be reviewed to ensure they are in line with good practice in respect of length of shift, additional hours worked and the number of consecutive days/nights worked. A range of policies should be available, shared and understood by staff, signed and dated by the manager and appropriate for the service This recommendation is repeated from the inspection of 21 February 2005 in respect of being routinely signed and dated. To evidence the verbal statement that all servicing of supplies and equipment have been carried out a safe current gas supply certificate should be on file in the home. Not assessed H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 28 Parkwood House Commission for Social Care Inspection The Oast, Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 Parkwood House H56-H06 S23988 Parkwood House V225902 070605 Stage 4.doc Version 1.30 Page 29 - 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. 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