Inspection on 07/12/06 for Richden Park

This inspection was carried out on 7th December 2006.

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

Richden Park 26/01/06

Richden Park 27/06/05

Richden Park 14/03/05

Richden Park 15/09/04

Richden Park 27/02/04

Richden Park 13/11/03

Similar services:

Snydale Care Home

Abbey The

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 Richden Park 37-43 Old Brumby Street Scunthorpe North Lincolnshire DN16 2AJ Lead Inspector Mrs Kate Emmerson Key Unannounced Inspection 7th December 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Richden Park DS0000002889.V325145.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. Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Richden Park Address 37-43 Old Brumby Street Scunthorpe North Lincolnshire DN16 2AJ 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) 01724 280587 richdenpark@bondcare.co.uk Bondcare Group Position vacant Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52) of places Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: Richden Park is a purpose built residential home. Accommodation is provided over two floors and there are two lifts to access the first floor. The home is registered for fifty-two service users under the category of old age. There is a small car park to the front of the building. Richden Park is close to the bus route into Scunthorpe centre, and Ashby. It is also close to local shops and churches. The home is in short walking distance to the town centre. Nursing care is not provided in the home and this is identified in the statement of purpose. Fees at the time of the inspection were £312 - £400. Additional charges were Hairdresser 35.00 - ££20, chiropody £8.00, newspapers - variable and outings - variable. Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two days in December 2006. To find out how the home was run and if the people who lived there were pleased with the care they got the inspector spoke to the manager and staff working in the home at the time of the inspection. The inspector also spoke to people who lived in the home. Of the twenty-two service users surveys sent out three were received back, of ten health and social care professional surveys sent out two were received and of ten relatives/visitor surveys sent out none were received. Some of the records kept in the home were checked. This was to see how the people who lived in the home were being cared for, that the staff had been trained to their job safely and to make sure that the home and the things used in it were safe and were checked regularly. A partial tour of the building was completed to check standards of cleanliness and maintenance. There had been an unstable period of management since June 2006 and which had impacted the extensive work completed by the previous manager to improve standards of care. The area manager supported the acting manager but they need to ensure that systems that have been put in place are maintained and that there is improvement in staff training and supervision and quality monitoring. Overall the service users continued to be satisfied with the care they received. What the service does well: Residents said that they had choices about how they lived their lives in the home, when they got up, went to bed, activities and meals. The service users enjoyed the meals they were provided with and they liked the staff who cared for them. The home was clean and tidy. The home gave detailed information to people about the home and how the care is given and they write to people to tell if their needs can be met in the home Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 6 Every resident had a care plan that described how the resident’s needs would be met. The plans of care were more detailed and most of the residents had seen and agreed to the care plan. What has improved since the last inspection? What they could do better: The information provided to residents must be more detailed and kept up to date when there are changes. They must ensure service users needs are assessed prior to admission to the home or in the case of an emergency on admission to the home. They must ensure that service users are regularly assisted to relieve pressure when they are unable to mobilise independently to prevent them becoming sore They must make adequate arrangements for service users to be able to attend out patient appointments including where necessary staff to accompany them so that appointments are not missed. They must ensure that any complaint made under the complaints procedure is fully investigated and records of the investigation are completed. They must make sure that the home is kept safe by replacing worn carpets and not storing items on top of wardrobes. There must be sufficient staff on duty to meet the service users needs. Staff must have regular training to do their job safely and to protect service users and have regular meetings with the manager where they can talk about how they are doing their job and training needs. The quality of the care in the home must be regularly checked and records that this has been done must be kept. Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had further developed the service users guide and statement of purpose to give information to prospective service users. Whilst these were informative they still did not include all the information required to meet the National Minimum Standards or Care Home Regulations 2001 and had not been updated in respect of management changes. The homes contract/statement of terms and conditions was only provided to permanent service users. All the service users had had their needs assessed but there was some inconsistency in application of formats and process of assessment. This may leave service users at risk of needs not being adequately met. EVIDENCE: Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 10 There was a statement of purpose and service users guide available in the home and the manager stated these were provided in each bedroom and at the reception area together with associated polices and procedures. The statement of purpose had been further developed to meet previous requirements and to meet the Regulation 4 and Schedule 1 of the Care Home Regulations 2001. However the document still requires some inclusions to meet the regulation and schedule for example the qualifications and experience of the Registered Provider. The service users guide had also been further developed, but to meet the standard the service users guide must include the qualifications and experience of the registered provider. The document had not been updated in relation to management changes. Both documents were written in plain English and were user friendly. The service users guide could be available in large print on request. A contract/statement of terms and conditions was provided to all service users except those on respite. Contracts/statements of terms and conditions must be provided to all service users. Four care files were checked; all service users had had their needs assessed prior to or on admission to the home. There were a number of documents including pre admission assessments and risk assessments completed as part of the assessment process. There was some inconsistency in application of the formats and how and when these were completed. Two service users had had assessments completed prior to admission but one service user had not had their assessment fully completed until eight weeks after admission. The home had obtained social service assessments and care plans in three cases. Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was a good standard of risk assessment, care planning, evaluation and review although there were some indications that over the month prior to the inspection evaluations had not been completed and there had been changes to diary records. Although there were no health issues identified at the inspection monitoring of service users health had not been consistently completed or taken into account when evaluating care plans. Health may be put at risk due the home not arranging sufficient staff to be on duty to accompany service users to hospital appointments. There were good procedures in place for the management and administration of medication. Service users felt their privacy and dignity was respected. Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 12 EVIDENCE: A random selection of four care plans was examined. Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 13 There was evidence that care plans had been developed from assessments of need. The care plans were detailed and had been evaluated monthly up to October 2006 and there was evidence that reviews had been completed. There was also evidence that these care plans had been agreed and signed in most cases. Where service users had been assessed as at high risk of pressure sore development a care plan to reduce the risks of pressure sore development had been developed. However where charts were in place to the frequency of care given these had not been used consistently and showed long periods where care may not have been given. There was evidence that nutritional screening was completed and evaluated regularly and weights were recorded. However it is recommended that evaluations take information such as weight changes into account when assessing if current care plans are meeting needs. Daily diary records were maintained but carers and seniors completed separate records, which were also filed separately. There was therefore some duplication of information and records of the care provided and service users health and wellbeing was difficult to follow. It is recommended that a single daily diary record be maintained. There was evidence form staff that at least two service users had missed hospital appointments due to lack of staffing arrangements being made for staff to accompany them. Records of the receipt, administration and disposal of medication, including controlled drugs, were clearly maintained. The temperature of medication storage areas was monitored. The staff member assisting the inspector had completed the safe handling of medication course and demonstrated good knowledge of the homes procedures and medications in general. Evidence from observation of practise, discussion with service users and staff indicated that the service users privacy and dignity were respected. The service users stated the staff were kind, used their preferred term of address and knocked on bedroom doors before entering. Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The services provided in the home were flexible and activities met service users needs. The service users maintained contact with their families as they wished. Service users received a varied and nutritious diet. EVIDENCE: The home employed an activities coordinator for 15 hours per week. There was a weekly activities plan that was displayed in the foyer. Records of activities undertaken by service users showed that they had been involved in activities, which included games, films, and one to one activities. A service user stated ‘there are activities arranged’ ‘I enjoy the entertainment we have, I can join in the singing’. Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 15 Information regarding access to records was provided in the service users guide. Service users confirmed that they were able to exercise choice in all their daily routines. At the previous inspection the manager had updated the menu following consultation with service users to offer an improved choice of alternatives. However at this inspection the area manager had altered the menus and choices at lunchtime had been reduced so some days of the week there was only one main meal choice but alternatives such as baked potato or omelette were always available. Comments about the quality of meals and choices available were varied and service users stated that food was ‘excellent and could not be faulted, it is well served and help is always at hand to help if you have difficulty feeding yourself’ others said it was ‘good’ and ‘ok’. There was evidence of home baking and fresh fruit was offered daily. Staff encouraged independence and aids were provided. Staff were seen to offer assistance when feeding service users in a sensitive and discreet manner. The kitchen was clean and tidy and all appropriate records were maintained. Richden Park DS0000002889.V325145.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home complaints procedures were made available to service users but there was evidence that not all complaints received were investigated. The home had systems in place to protect service users from abuse and some of the staff had received training in this area but there had been no provision made for staff to receive regular updates and there were some deficiencies in the provision of induction. EVIDENCE: Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 17 The homes policies and procedures for complaints were observed and found to be appropriate to the needs of the home. A copy of the policy and procedure was displayed in the reception area, in bedrooms, and in the information provided to prospective service users in the service users guide. The policy states that complaints will be responded to within 28 days, and a record book is kept to record any complaints and the outcome of any investigation. The Commission had received six complaints since the last inspection. The areas of concern included medication administration, confidentiality, cleanliness of the home, removal of flowers, care provision, call bells not being answered. Three of the complaints were founded, one was partially founded and two did not have any details of investigation or outcome recorded. The home had policies and procedures for the protection of vulnerable adults, and it makes reference to the reporting systems to the local authority, and the Commission. A copy of the local authorities policies and procedures for the protection of vulnerable adults was available in the home. Eleven staff had received formal training for the protection of vulnerable adults in 2005. A training plan provided by the area manager following the inspection indicated that training was to be provided in January 2007. There was evidence that staff received vulnerable adults training as part of induction although records of induction were not available for the more recently employed staff. Richden Park DS0000002889.V325145.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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was generally clean and tidy, comfortable and reasonably well maintained. There were some potential hazards for service users in relation to a carpet and storage of continence aids. EVIDENCE: A partial tour of the building was undertaken. The standard of cleaning in the home had been maintained, only one room was found to be odorous. Maintenance records were completed by the handy man. Service users stated they were happy with the cleanliness of their room. Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 19 A new managers office had been built and this was now an internal part of the home. This was of great benefit to all concerned and the manager was more accessible to staff and service users. Ramps had been built to make the gardens more accessible The carpet to the hallway near the lift on the Brumby unit was very worn and loose and was a potential trip hazard. The linen cupboard on this side was unlocked and there were some continence pads stored on top of a wardrobe in a service users bedroom that was a potential hazard. The floor in the ground floor bathroom on Richden unit was very marked/stained and the area had been used to store moving and handling equipment. Overall this area did not provide for a very relaxing and pleasant bathing experience. The water temperatures were found to be in acceptable limits except in the ground floor bathroom on Brumby unit where the temperature was above 50°C. The bathroom was taken out of commission and the handyman adjusted the valves. This was checked again and found to be within acceptable limits. The handy man provided evidence that the hot water temperatures were checked monthly. There was also evidence that room temperatures were tested monthly. There was evidence that the home complied with the Water Supply (Water fittings) Regulations 1999 and that there were systems in place to minimise the risks of Legionella. Richden Park DS0000002889.V325145.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was a slight deficiency in the staff numbers to be provided on each day shift and this had impacted in some areas of the homes ability to meet service users needs. Staff received training relevant to their role and to work safely. There were some deficiencies in induction training records. A training plan must be developed and implemented to ensure that mandatory training requirements continue to be met. Recruitment practises were adequate but deficiencies regarding references and supervision must be addressed to ensure full protection for service users. EVIDENCE: Service users stated that the staff were ‘very good’ they were ‘happy with the care provided’ and they were ‘well looked after’. One service user said staff tell them they are short staffed and sometimes they have to wait up to ten minutes for care. The home had forty one service users accommodated and provided day time staffing as six am, five pm plus an activities coordinator for three hours pm Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 21 five days per week. The area manager was advised that for forty-one service users the home must provide six staff on duty at all times for daytime shifts. A senior carer is always on duty and is in charge of the home in the absence of the manager. There were some issues raised by the staff group who stated that recent management changes had affect staff morale although this was beginning to improve. They were concerned that at least two service users had missed hospital appointments due there being no staff member or family to accompany them. This is not acceptable and must be addressed. Four of the twenty-four care staff have achieved NVQ level 2 and nine have registered to commence training. The domestic staff have completed NVQ level 1 in housekeeping. TOPPS induction training had been introduced to the home but there was evidence that this had not been consistently applied for recent new starters and induction records could only be located for one of three new starters. There was evidence that these staff had received moving and handling and fire safety awareness training. The area manager stated that he was just brining the training file up to date and preparing a training plan. He stated that moving and handling training, fire safety and safe handling of medications were planned or being completed by the staff. A training plan was provided following the inspection, which indicated the training to be provided in 2007. Information on training completed by staff to date, also provided following inspection, indicated gaps in mandatory training and these need to be addressed. Three new starters files were checked, the home had obtained all the required checks prior to the staff starting work. However the home is advised that references must be authenticated and it is recommended that they send for references themselves rather than accepting those brought in by staff. Where staff have started work following receipt of a POVA first check but before receipt of the full CRB, staff must be supervised at all times and evidence of this kept. A staff member confirmed that he had not worked alone since starting on a POVA first check. Richden Park DS0000002889.V325145.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had an experienced deputy manager acting up as manager with support from the area manager. The company were actively seeking a new manager. The home did not monitor the quality of the services provided although the quality of the care has significantly improved over the last eighteen months. The home had processes in place to safeguard service users finances. Records could be more transparent. Staff supervision had not been continued following a change in management. Senior staff had received training to provide supervision. Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 23 The home had policies and procedures in place to manage health and safety. Gaps in mandatory training had been identified and a training plan developed to address these. EVIDENCE: The home has been through an unstable management period since June 2006 with the previous manager leaving and the new manager only staying at the home for four weeks. Vanessa Cole, Deputy manager, with support from Paul O’Grady, area manager, is currently managing the home. Vanessa is an experienced carer and has worked in a senior position in her previous post for many years. Vanessa started at the home in June 2006 as deputy manager and the Commission were advised she became acting manager on 25 September 2006. The company have continued to advertise for another manager and recently held interviews. There was no evidence that the home had any processes in place to monitor the quality of the care in the home and there was little evidence that service users were consulted on the quality of the service they received. The home had only held one service users meeting in 2006. There was a wide range of detailed policies and procedures in place although some of these were not applicable to the homes registration as they were based on clinical procedures for nursing homes and these must be reviewed. The records for financial transactions on behalf of the service fusers were examined and these balanced with cash held and receipts were available for purchases. However more care must be taken to reduce errors and crossings out in the records. Witnessing of each transaction, a written explanation of any errors and regular management checks are advised to ensure transparency. Senior staff had been on a supervision course to assist the manager in providing staff supervision. A programme of supervision had been set up and some staff had received one session but this had not been continued following management changes. The home had systems in place to manage health and safety in the home and appropriate records were maintained. The majority of checks of equipment had been completed and certificates were available, except for hoist service certificates, which the administrator stated had been completed the day before the inspection and they were waiting for the certificates to be provided. There was no evidence that safety checks of portable electrical equipment had been completed. Certificates to evidence that the fire alarm system and emergency lighting had been serviced were provided after the inspection. Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 24 Moving and handling training had been provided in November 2006 and all but four care staff had attended this and fire safety awareness training had been provided thought the year but six staff had not attended this. Ten staff held first aid certificates. There were gaps in provision of mandatory training such as health and safety and infection control identified in the information provided to the inspector following the inspection but a training plan had been developed which should address the shortfalls by April 2007. Richden Park DS0000002889.V325145.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 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 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 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 1 X 2 Richden Park DS0000002889.V325145.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 OP1 Regulation 4 Requirement The registered person must ensure that the statement of purpose includes all the information as listed in Schedule 1 of the Care Home Regulations 200. (Previous timescale 1 October 2005 and 1 April 2006 not met) The registered person must include in the service users guide all the information listed in Standard 1 and Regulation 5 of the Care Home Regulations 2001. (Previous timescale 1 October 2005 and 1 April 06 not met) The registered person must ensure that all service users are provided with a contract/statement of terms and conditions The registered person must ensure service users needs are assessed prior to admission to the home or in the case of an emergency on admission to the home. The registered person must ensure that service users are DS0000002889.V325145.R01.S.doc Timescale for action 01/03/07 2. OP1 5 01/03/07 3 OP2 5 01/02/07 4 OP3 14 14/01/07 5 OP8 13(4) 14/01/07 Richden Park Version 5.2 Page 27 6 OP8 13(1) 7 OP16 22 8 OP18 13((6) 9 OP19 13(4) 10 OP19 23(20 11 12 OP19 OP27 23(2) 18(1) 13 OP29 19 regularly assisted to relieve pressure when they are unable to mobilise independently. Records of assistance provided must be maintained. The registered person must make adequate arrangements for service users to be able to attend out patient appointments including where necessary staff to accompany them. The registered person must ensure that any complaint made under the complaints procedure is fully investigated and records maintained. The registered person must ensure that all staff receive training in protection of vulnerable adults and associated procedures. The registered person must ensure that all environmental hazards are removed, Brumby first floor hall carpet to be replaced where worn, Brumby linen cupboard to be kept locked, continence aids not to be stored on top of wardrobes. The registered person must ensure that the Richden ground floor bathroom flooring is replaced if staining cannot be removed. The registered person must ensure that the bathrooms are not used as storage areas. The registered person must ensure that there are sufficient staff on duty to meet the needs of the service users. There must be at least six staff on daytime shifts for forty-one service users. The registered person must ensure that staff employment refernces are authenticated and staff working prior to receipt of a full CRB but with a POVA first are DS0000002889.V325145.R01.S.doc 07/12/06 07/12/06 01/02/07 01/02/07 01/03/07 01/02/07 07/12/06 14/01/07 Richden Park Version 5.2 Page 28 14 OP30 18(1) 15 OP36 18(2) 16. OP33 24 17 OP38 13(4) 23(2) constantly supervised and records of the supervision maintained. The registered person must ensure that all new staff receive induction training within six weeks of employment, foundation training within six months of employment and mandatory training with appropriate refresher training as an ongoing programme (The previous timescale 26 January 2006 was not met). The registered person must ensure that staff receive a minimum of six formal recorded supervision sessions per year. (The previous timescale - 1st January 2005, 1 June 2005 and 1 October 2005 and 1 April 2006 was not met) The registered person must ensure that there is an effective quality assurance and quality monitoring system in the home that includes an action plan and publication. (The previous timescale - 1 January 2005, October 2005 and 1 April 2006 -was not met) The registered person must provide evidence to the Commission that moving and handling equipment has been serviced and portable electrical equipment has been safety checked. 01/03/07 01/02/07 01/03/07 01/02/07 Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 29 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 OP35 Good Practice Recommendations The registered person should ensure that a single daily diary record is maintained. The registered person should ensure that all transactions on behalf of service users are witnessed, that there is a written explanation of errors in records and that regular management checks of the records are completed. Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Richden Park DS0000002889.V325145.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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