Inspection on 19/03/08 for Pearson Park Care Home

This inspection was carried out on 19th March 2008.

CSCI found this care home to be providing an Adequate service.

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

Pearson Park Care Home 13/01/09

Pearson Park Care Home 20/03/07

Pearson Park Care Home 24/01/06

Pearson Park Care Home 19/07/05

Pearson Park Care Home 11/11/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Pearson Park Care Home 1-2 Eldon Grove Beverley Road Hull East Yorkshire HU5 2TJ Lead Inspector Diane Wilkinson Key Unannounced Inspection 19th March 2008 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pearson Park Care Home Address 1-2 Eldon Grove Beverley Road Hull East Yorkshire HU5 2TJ 01482 440666 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) Mrs Kim Crosskey Mrs Kim Crosskey Care Home 24 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24), Old age, not falling within any other of places category (24) Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Staffing must meet the levels set by the residential forum. To admit one service user under pensionable age whose name is contained within the CSCI file. The Home may provide care for a maximum of 5 service users who are between the ages of 60 to 65 and who have an illness which presents to that of old age. 20th March 2007 Date of last inspection Brief Description of the Service: Pearson Park Care Home is registered to provide care and accommodation for 24 older people, including those with dementia. The home is close to the city centre and to local amenities, such as shops, public houses, cafes and hairdressers. Private accommodation is provided in 10 single bedrooms and 7 shared rooms. Communal rooms consist of a dining room and a large lounge, and are situated on the ground floor. Bedroom accommodation is on both the ground floor and the first floor; access to the first floor is via a passenger lift. There is a private walled garden to the rear of the home and a separate car parking area. The home is situated close to Pearson Park and this provides residents with a pleasant area where they can take a walk. Information about the home is provided to residents and others in the home’s statement of purpose and service user’s guide. The registered manager told us that the weekly fees are currently £338.00 to £368.00 per week. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on 20 March 2007, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 10.30 am and ended at 3.40 pm. On the day of the site visit the inspector spoke on a one to one basis with two residents, a relative, a member of staff and the registered provider/manager, as well as chatting to other residents and staff. Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The registered person submitted information about the service in advance of the site visit by completing and returning an Annual Quality Assurance Assessment (AQAA) form. Comments from discussions with residents and others were mainly positive, for example, ‘The food is very nice and I can have a cup of tea any time I want one’ and ‘the rooms are nice and clean – there is always someone tidying up’. Other anonymised comments are included throughout the report. What the service does well: Care plans include thorough assessments of care needs; these are reviewed regularly to ensure that there is an up to date record of each person’s care needs. Good links are maintained with health and social care professionals to ensure that resident’s received the support they require. Residents are supported to be as independent as possible and to maintain their previous lifestyle. Visitors are made welcome to the home and residents are supported to keep in touch with family and friends. Staff are well trained and this equips them to care for the residents living at the home. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 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 Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are assessed prior to their admission to the home and only admitted if it is considered that their assessed needs can be met. EVIDENCE: We examined the care records for a newly admitted resident. These included a client admission detail form and two risk assessments, one for nutrition and one for dependency levels. The client admission form includes information about a person’s social, medical and psychiatric history along with details of their next of kin and GP. The registered person confirmed that people are visited by staff at their current place of residence prior to their admission and that this is when the initial assessment of needs commences. There is evidence that people are Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 9 only offered a place at the home if it is believed that their current assessed needs can be met, and in some instances, a period of respite care is arranged to assist people in making a decision about permanent care. Information gathered in the initial assessment undertaken by the home together with information received from Care Management (when people are placed by the local authority) are used to begin to develop an individual care plan for new residents. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning documentation evidences that health care needs are met in a way that respects a person’s privacy and dignity. Some improvements need to be made to medication systems to promote safety for residents. EVIDENCE: We examined the care records held for three residents. These included a thorough needs assessment and risk assessments for nutrition, dependency levels and manual handling needs. In addition to this, a community care assessment and care plan developed by Care Management had been obtained for those people placed by the local authority. In addition to this, some individual risk assessments have been completed for such areas as the risk of falling out of bed, going out alone and the risk of scalds or burns (for someone who has a kettle in their bedroom). Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 11 These assessments are used to develop an individual care plan for each resident. We observed that residents sign to record their agreement to their individual plan of care. There are written agreements in place for the use of bed rails; the registered person was advised that they also need to complete a risk assessment for each individual that uses a bed rail, and that bed rails need to be checked for safety on a regular basis. We noted that some care plans did not include a photograph of the resident; photographs are needed to assist new staff with identifying residents and to assist emergency services in the event of a resident being missing from the home. The care plan includes a monthly review for each care plan area and for each risk assessment; this is good practice. We saw that the care plan had been updated where necessary as part of these monthly reviews. Some service users have had a formal review of their care plan undertaken by Care Management and records show that residents and their relatives are invited to attend. It was not clear if the home had arranged in-house reviews for privately funded residents. Daily diary sheets are a record of care provided, visitors seen and diet taken. Visits from health care professionals, including the reason for the visit and any outcome, are recorded in individual care plans and we noted that this information is cross referenced to daily diary entries. There is evidence that the home has close links with mental health care professionals and that this enhances the mental well being of the residents accommodated at the home; one person is supported to attend a Memory Clinic. Appropriate referrals are made to GPs and specialists to try to alleviate health care concerns. We saw that continence care and pressure care is managed appropriately, and that some people now have a pressure care assessment in place. Most people are weighed on a regular basis as part of nutritional screening. We examined medication administration records on the day of the site visit; these include a photograph for each resident and sample signatures for staff that have responsibility for administering medication; this allows records to be checked for authenticity. There is evidence that the staff that have responsibility for the administration of medication have undertaken accredited training. Recording on medication administration records was not accurate and it was also noted that staff do not record when residents refuse ‘as required’ medication. The registered person was advised that staff should record when residents have refused medication, as this evidences that it has been offered to residents. The storage and recording of controlled drugs is satisfactory; records include the signature of two staff each time medication is administered and there is a ‘running total’. We checked some medication against records Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 12 held and these were found to balance. No excessive stocks of medication are kept on the premises and the records for medication returned to the pharmacist were found to be satisfactory. We observed the administration of medication at lunchtime; medication was taken to each service user in a ‘nomad’ pack and service users were offered a drink with which to take their medication. Staff were seen to sign medication administration records before residents actually took their medication; medication records must only be signed when residents have actually taken their medication. Some residents have a single room but there is no other area of the home where residents can see visitors and health and social care professionals in private. There are curtains available to be used in shared rooms to promote privacy and dignity for service users. We observed that service users are treated sensitively by staff regarding assistance with personal care. Residents and relatives that we spoke to on the day of the site visit confirmed that they are treated with respect and that their right to privacy is promoted. There is no longer a male carer at the home but some male residents that we met said that they were not concerned about being assisted by a female carer. The minutes of the most recent residents meeting record that residents said that staff were ‘very attentive, helpful, polite and gentle’. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to make choices about their day-to-day lives and benefit from opportunities to take part in social activities and individual interests. Information about advocacy services is not readily available and meal provision at the home would be enhanced if there was a choice of meal at every mealtime. EVIDENCE: We observed that care plans record the previous lifestyle of service users, including leisure and social interests and likes and dislikes. In addition to this, care plans record a person’s preferred time to get up and go to bed. Residents told us that they are supported to maintain their previous lifestyle as far as is possible. Residents are able to make some choices within their capabilities, for example, where and how to spend their day and where to take their meals, and are encouraged to be as independent as possible. Some residents that we spoke to on the day of the site visit told us that they enjoy going out for a Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 14 walk; some are accompanied by staff and others are not, depending on the wishes and the mobility needs of the resident. On the day of the site visit to the home residents were taking part in art and aromatherapy sessions, and a member of staff organised a game of bingo. Some people told us that they prefer to spend their day in their bedroom, reading or watching TV. Daily records include information about a person’s daily routine including food and drink intake and any trips out. However, they do not include information about any activities undertaken. The registered person told us that there is a separate record kept of all activities offered at the home and we saw this on the day of the site visit. We advised the registered person that this information should be recorded in care plans so that there is a full picture of the care provided for residents. Residents told us that they are assisted to keep in touch with family and friends, and to have contact with the local community. They told us that their visitors are made welcome by staff at the home and there is evidence that relatives and friends continue to be involved in the lives of service users, if this is their wish. Some residents have their own telephone to enable them to contact family and friends easily. A relative told us that they are kept informed of important events concerning their relative and that they are very satisfied with the care offered by the home. The registered person told us that residents are told about available advocacy services if it is felt this would be beneficial; they were advised to obtain information to be displayed in the home. This would enable people to access these services independently without having to ask for advice. We noted that residents are able to bring some of their possessions into the home and are able to personalise their bedrooms. On the day of the site visit the meal provided at lunchtime looked appetising and service users told us that they had enjoyed it. There was no menu on display, although the registered person told us that this was an oversight, and that there is usually a menu on display; a menu may encourage residents to become involved in meal provision at the home and may initiate conversation. Most residents had their lunch in the dining room, but some were assisted with their meal whilst sitting in the lounge. Residents told us that they would be provided with an alternative meal if they requested one, and one person had a sandwich on the day of the site visit instead of the meal provided. The registered person told us that the cook is aware of a person’s likes and dislikes. However, there is no real choice of meal at lunchtime. We discussed the provision of a cooked breakfast with the registered person. She said that she has found that residents are unable to eat their lunch if they have a cooked breakfast. There should be evidence that this has been discussed with residents; it may be possible to provide a cooked breakfast at Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 15 weekends and to have lunch a little later – lunch is currently served between 11.30 am and 12 noon. We noted that residents were offered appropriate assistance with eating and drinking, and observed that an ample supply of drinks was made available during the day; service users that remain in their bedrooms had been provided with a jug of water or juice. One resident said, ‘The food is very nice and I can have a cup of tea any time I want one’. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information is provided about how to make a complaint and residents and others know who to speak to if they have any concerns. There are policies and procedures in place on safeguarding adults but appropriate people are not informed when there has been an allegation or incident of abuse. EVIDENCE: We observed that the complaints procedure is displayed in the entrance hall. The Annual Quality Assurance Assessment (AQAA) form completed by the registered person records that there have been no complaints made to the home since the last key inspection, and no complaints have been received by the CSCI. There is no complaints log available at the home to record any complaints made and one should be produced. Residents and relatives told us that they knew who to talk to if they had any concerns, and that they were confident that they would be dealt with. The registered person recorded in the AQAA form that there have been no allegations or incidents of abuse at the home. Since this site visit to the home it has come to the attention of the CSCI that there has been an allegation of abuse that is currently being investigated by the local authority Social Services Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 17 department – this incident occurred after the registered person had completed the AQAA form but before the site visit to the home. The registered person did not inform CSCI of this incident as is required by regulation. We observed in training records that six members of staff have attended training on safeguarding adults from abuse. The registered person told us that they speak to all staff individually about safeguarding adults procedures but there is no evidence available to support this. All staff should undertake this training to ensure that they have a full understanding of the concept of abuse, and that they have the skills to recognise incidents of abuse and know how to deal with them. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 and 26 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Communal and private areas of the home were clean and hygienic on the day of the site visit but the premises were not being maintained safely and posed a risk to residents. EVIDENCE: There is no maintenance programme in place but work was taking place on the day of the site visit to improve and maintain the environment. Due to the maintenance work that was being carried out at the home, corridors and communal areas of the home had building materials stored in them; this posed a risk to residents and staff. We found a spare mattress being stored in a resident’s bedroom and continence products were stored in various corridors and communal areas. Any areas of the home that are accessible to residents Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 19 must be kept safe and free from potential hazards, and suitable storage areas must be made available for spare equipment and continence products. One bedroom is located along a corridor that includes 4 large steps – there is also access to a flight of stairs close to the bedroom. Because this is a fire exit, the door leading to it cannot be locked. The registered person is required to complete a risk assessment regarding the resident who is accommodated in this bedroom to evidence that all potential risks have been minimised. Improvements have been made to the garden and it now provides residents with a safe and pleasant area to sit outside. We noted that the home is registered to accommodate 24 residents, but there are not enough chairs in the lounge or dining room to accommodate 24 people. There is a large lounge and a dining room, but no area for people to meet with visitors in private or to sit quietly. All activities have to take place in the lounge. Furnishings and lighting in communal rooms is satisfactory. Contractors were working at the premises on the day of the site visit. The bathroom was in the process of being refurbished and could not be used by residents. Another bathroom had been converted into a walk-in shower room but was not ready for use. A third bathroom was available for use but several steps had to be negotiated to access the bathroom and it had no mobility hoist to enable people to be assisted to get in and out of the bath. The registered person told us that only a few residents were able to use this bathroom and that, during the period of refurbishment, residents were being assisted to have a strip wash or a bed bath. An immediate requirement notice was left on the day of the site visit requiring this work to be completed by the 28th March 2008. We contacted the registered provider on that date and it was confirmed that both the new bathroom and the new shower room were fully operational. The laundry room is accessed via the garden area and it was noted that this was untidy and in need of refurbishment to provide impermeable surfaces that could be kept clean and hygienic. The laundry room was not locked on the day of the site visit and cleaning materials are stored in this room; this creates a potential hazard for residents. The central heating boiler is located in the laundry room – the outer casing looked beyond repair and was held together with tape. However, on checking, we noted that there is a service certificate in place for the boiler. Private and communal areas of the home were found to be clean and hygienic on the day of the site visit and staff were seen to follow hygiene practices that promoted infection control. One resident told us, ‘the rooms are nice and clean – there is always someone tidying up’. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty to care for the number of residents accommodated, but improvements need to be made to recruitment practices and to induction training to ensure the safety of residents. EVIDENCE: There is a staff rota in place that records the number of staff on duty and the role of each member of staff. The care staff recorded on the rota were seen to be on duty, and the rota records that there is a cook on duty every day. There was no domestic and no handyman recorded on the staff rota but both were seen to be on duty. The staff rota evidences that there are sufficient numbers of staff on duty throughout the day. Three or four care workers have achieved National Vocational Qualification (NVQ) Level 2 in Care and this falls short of the requirement for 50 of care staff to have gained this award. A further 3 or 4 staff are currently working towards this award. There should be an action plan in place that records how the requirement for 50 of care staff to achieve this award will be met by the home. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 21 We examined the recruitment records for two members of staff. There is an appropriate application form in use that records a person’s employment history, any qualifications obtained and any training undertaken. A Protection of Vulnerable Adults (POVA) first check had been received for both care workers, but one of these had arrived after the person commenced work at the home, and one carer had commenced work before two written references had been received. A reference had been accepted from a friend when there were more suitable people available to give a reference. The registered person was reminded that a Criminal Records Bureau (CRB) check should be obtained before staff commence work at the home, and that a POVA first check should only be used in exceptional circumstances. Staff should then work under supervision until their CRB clearance is received. Documents to verify a person’s identification are obtained and retained in the home. New staff undertake induction into the home but there was no evidence that a formal induction programme that meets Skills for Care requirements is undertaken within six weeks of staff commencing work at the home. There is a training and development plan in place and this records that staff have undertaken a variety of training programmes, including health and safety, risk assessment, moving and handling, safeguarding adults, food hygiene, infection control and dealing with an emergency. In addition to this, staff have undertaken more specific training to assist them to carry out their role, such as Parkinson’s Disease, Supervision Skills, the Mental Capacity Act and Stroke. The training and development plan records the date that training has been undertaken and the dates of any refresher training; this is good practice. Some training records were disorganised; a training and development plan that records the achievements and needs of the full staff group in one document should be produced. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed but there needs to be a registered manager in post that has achieved the required qualifications. The quality assurance system needs to expand to include other stakeholders so that they are able to comment on the way in which the home is operated. EVIDENCE: The home is managed by the registered provider, who told us that she works alongside care staff so that she continues to be fully aware of the needs of residents and is able to monitor the practice of care staff; she is a qualified Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 23 mental health nurse and fully understands the needs of older people with dementia. The registered person told us that she subscribes to nursing journals and that this helps to keep her own practice up to date. Whilst at the home she has achieved a great deal with the service users and has improved the quality of life of some by encouraging them to join in social activities and social interaction so alleviating their isolation. The manager does not intend to undertake the Registered Manager’s Award. The deputy manager has achieved NVQ Level 3 in Care and is due to commence the Registered Manager’s award; the registered person was not aware that the deputy manager would also need to undertaken NVQ Level 4 in Care if they were planning to apply to the CSCI for registration as the manager. The registered person returned the AQAA form as requested and this had been completed thoroughly to include all of the information we required. There is a quality assurance system in operation at the home. A survey was undertaken in September 2006 and the results of the survey have been collated. The registered person told us that this information was fed back to residents at a resident’s meeting. A further survey took place in July 2007 but the results of this survey have yet to be collated and acted upon. The registered person was advised that quality monitoring via surveys should be expanded to include relatives and health/social care professionals. The AQAA form records that most policies and procedures were reviewed by the registered person in August 2007. We saw evidence that residents and staff meetings are held on a regular basis. Minutes of the most recent residents meeting evidence that residents were asked if they are satisfied with the menu and the laundry service, and that activities and trips out were discussed. We examined monies held on behalf of residents and associated records on the day of the site visit. These were found to be accurate; records include monies received by the home, monies paid out and a running total, and receipts are obtained. The registered person told us that there is always petty cash available should residents ask to have access to their money whilst she is not present at the home. We examined service and maintenance certificates for equipment and systems, such as the gas safety certificate, the passenger lift and mobility hoists – all were up to date. An annual test of the fire alarm system took place in December 2007 and in house fire tests are undertaken on a regular basis. There is an action plan in place as required by the Fire Department; this records that the front door should not be locked, but that if it is locked, the key must be available at all times. Water temperatures at outlets accessible to residents are tested on a regular basis to alleviate the risk of scalding, and the water system has been tested to detect the presence of Legionella; this was negative. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 24 As previously recorded, the home was not being maintained in a safe way on the day of the site visit, and staff are not recruited following robust procedures. Both of these issues pose a risk to the health and well-being of residents. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 2 1 X X X X 2 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 26 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 OP18 Regulation 37 Timescale for action The CSCI should be notified of all 19/03/08 allegations or incidents of abuse concerning residents living at the home. This enables us to monitor the effectiveness of the reporting systems in place at the home. All areas of the home that are accessible to residents must be kept free from potential hazards. There must be a risk assessment in place regarding the resident who is accommodated in the identified bedroom, to evidence that risks have been minimised. 19/03/08 Requirement 2. OP19 13 3. OP19 13 16/05/08 4. OP21 23 There must be sufficient bathing 28/03/08 facilities that meet the needs of residents living in the home. An immediate requirement notice was left at the home in respect of this. The registered person confirmed that they had actioned this requirement within the given timescale. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 27 5. OP29 18 & 19 The registered person must ensure that a CRB check (or POVA first check in exceptional circumstances) is obtained prior to staff commencing work at the home. Two written references must also be in place prior to staff commencing work. Previous timescale of 30/07/07 not met. 19/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Each care plan should include a photograph of the resident. This assists new staff to recognise people and assists the emergency services with identification should someone be missing from the home. There should be risk assessments in place for the use of bedrails for individual residents, and regular safety checks should take place on bed rails; these checks should be recorded. Staff should only sign the medication administration record when residents have actually taken their medication. More care should be taken when completing medication administration records to ensure accuracy. Staff should record ‘R’ when residents refuse ‘as required’ medication. There should be a private area of the home for residents to meet visitors and health/social care professionals. Care plans should include information about activities that residents have taken part in to provide a full picture of the care provided. Information about advocacy services should be available in the home to promote independence and to allow easy access to this information. Residents should be offered a choice of meal at each mealtime. There should be a complaints log in place so that any complaints can be recorded and monitored. DS0000061233.V360785.R01.S.doc Version 5.2 Page 28 2. OP8 3. 4. 5. 6. 7. 8. 9. OP9 OP9 OP10 OP12 OP14 OP15 OP16 Pearson Park Care Home 10. OP18 11. 12. 13. 14. 15. 16. 17. OP20 OP26 OP28 OP29 OP30 OP31 OP33 All staff should undertake training on safeguarding adults to ensure that they are able to recognise bad practice and that they know what action to take should an incident of abuse occur. There should be sufficient communal space to accommodate the number of residents that the home is registered to accommodate. Laundry facilities should be made safe and hygienic. There should be an action plan in place to record how 50 of care staff will achieve NVQ Level 2 in Care. Staff that commence work following a POVA first check should be supervised until a satisfactory CRB check has been received. Staff should undertake an induction programme that meets Skills for Care requirements within 6 weeks of commencing work. There should be an action plan in place to record how the home plan to ensure that there is a manager in post who has achieved the required qualifications. The quality assurance system should be expanded to include surveying relatives and others to give them the opportunity to express an opinion about how the home is operated. Pearson Park Care Home DS0000061233.V360785.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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