Inspection on 01/12/05 for South Park

This inspection was carried out on 1st December 2005.

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

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

Other inspections for this house

South Park 19/09/07

South Park 11/01/07

South Park 25/05/06

South Park 08/06/05

South Park 16/11/04

South Park 29/06/04

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 South Park Gale Lane Acomb York North Yorkshire YO24 3HX Lead Inspector Jo Bell Unannounced Inspection 1st December 2005 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 South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service South Park Address Gale Lane Acomb York North Yorkshire YO24 3HX 01904 784198 01904 785234 south.park@fshc.co.uk 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) Ringdane Limited `Wholly owned subsidiary of Four Seasons Health Care` Miss Judith Margaret Clapham Care Home 102 Category(ies) of Dementia - over 65 years of age (49), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (49), Old age, not falling within any other category (53) South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home also provides 8 day care places plus 8 day care beds. Service users in the category of OP are 60 years plus - Jorvik Unit. Service users to include up to 49 DE(E) and up to 49 MD(E) up to a maximum of 49 service users - Ebor Unit. 7th June 2005 Date of last inspection Brief Description of the Service: South Park Care Home is part of the Four Seasons Health Care Group. The Home accommodates up to 102 older people who require general nursing care and mental health nursing care. The Home is a two storey building in its own grounds with gardens to the side and back of the home.There is level access to the home and a passenger lift to the first floor. The Home operates two distinct units under one registration, Ebor is for service users with mental health needs, and Yorvik is for general nursing care. The home also also offers day care for up to 8 sevice users South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The 2nd unannounced inspection took place on Thursday 1st December 2005.Two inspectors spent seven hours at the home. A tour of both Ebor and Jorvik wing took place. The home had 97 residents at the time of the inspection. Previous requirements regarding the environment, care plans, infection control and health and safety were discussed. The management of the home, resident’s finances, staffing levels and training were also assessed. The home have developed a person centred care approach which has been introduced on the mental health wing. This has had a positive effect on the residents and staff. Staff have a good understanding of adult protection and the home offer a range of training to ensure staff are competent in their roles. Staffing levels were adequate and residents confirmed that their needs could be met. The home is aware that elements of the environment need improving. At the inspection two immediate requirements were issued relating to water temperatures and radiator covers. What the service does well: The home have a good quality assurance system in place which ensures the views of residents, staff and relatives are sought. Privacy and dignity is maintained in the home. The home have detailed care plans in place which identify specific care required for individuals with general nursing and mental health needs. Risk assessments for moving and handling, use of bed rails, prevention of pressure sores are routinely completed and reviewed. The training in the home is good, staff confirmed that they receive adult protection training, Care staff are offered NVQ training and a robust training matrix is in place. The limited activities available were well received on Jorvik Wing. A sing-a-long took place which residents clearly enjoyed. The activities organiser is keen and motivated but is aware that as she is part time it is a challenge facilitating activities for all areas of the home. The manager stated that this is to be addressed shortly with another activities organiser. South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 6 The manager of the home is professional, friendly and encourages an open culture. What has improved since the last inspection? What they could do better: Residents stated that the food had improved over the last few months. However, it was evident that communication between the catering staff and care staff is poor regarding resident’s individual needs at mealtimes. The chef did not know which residents were undernourished but had observed plates of untouched food been returned to the kitchen. The care staff must identify residents with dietary needs and ensure this is monitored and followed up appropriately. The sluice area on Ebor Wing was dirty, the floor had brown stains on it, the pipes were boxed in with broken and cracked material and the commode pots and containers in the sluice were in need of a thorough clean. The sluice room on Jorvik Wing had an extremely strong smell of urine which was present as soon as the door was opened. The water temperatures in the home were variable, nine temperatures taken were over 43 degrees centigrade. Three of these were 50 degrees or above. These had been checked on 22nd November and whilst some action had been taken the issue had not been resolved. An immediate requirement was issued. On Ebor Wing most of the radiators did not have appropriate guards in place. The covers had large gaps (full width of the radiator and approximately 8 inches in depth) where a resident could put their hand onto the radiator and be at risk of burning themselves. One radiator on Ebor Wing next to the fire exit was very dirty. The top of the radiator was level with the gap where the guard should have been placed. An immediate requirement was issued. The home must provide adequate storage space for moving and handling equipment and wheelchairs, this is to comply with fire safety regulations. South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 7 The lounge area on Ebor Wing is too small, there are an insufficient number of chairs and residents are having to sit in extremely close proximity to each other. One resident was sitting on a small stool, another resident was sat in a ‘bucket chair’ which was not appropriate. 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. South Park DS0000027981.V266279.R01.S.doc Version 5.0 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 South Park DS0000027981.V266279.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these Standards were assessed (Standard 6 is not applicable) EVIDENCE: South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 & 10 Residents care needs can be clearly identified through the detailed plans of care, in general these needs are met. Residents have access to a range of healthcare services and staff positively maintain privacy and dignity. EVIDENCE: Eight service user plans were examined, four from each area. A significant improvement had taken place since the last inspection regarding the quality of the care plans. Detailed risk assessments were in place for moving and handling, prevention of pressure sores, falls prevention and the use of bed rails. Those care plans inspected had clear information relating to the care needs of individuals. Social history and cognitive information was completed on those residents with mental health needs. Review dates were in place and the care was evaluated on a monthly basis. Seven out of the eight care plans had nutritional assessments in place, the home have obtained scales which can be used with the hoist and sling. This is especially beneficial for those residents who cannot be weighed using sit on scales. A care plan is implemented if the nutritional assessment is determined as a medium risk or higher. One lady had details relating to a pureed diet and the use of build up drinks. As discussed in Standard 15 the home need to South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 11 ensure they are consistently aware of specific nutritional needs of individuals. The manager is aware of how to refer to the GP and community dietician. Evidence of continence assessments, visits by the chiropodist and referral to healthcare services was available in service user care plans. One lady had developed a pressure sore, even though the tissue viability nurse had not been contacted it was felt the staff had sufficient experience and knowledge to provide appropriate treatment. This was evident as the pressure sore had healed. This person had signed her own care plan, had a prevention of pressure sore chart completed with a specific care plan and pressure relieving equipment had been put in place. Privacy and dignity in the home was observed to be maintained. Staff were addressing residents in a polite and friendly manner. One new resident said the staff call her by her preferred name, they explain everything to her and when they are giving personal care they close the curtains and always knock on the door prior to entering. Carers spoken with said they know how to address residents and are aware of the importance of knocking on resident’s doors. South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14 & 15 Service users who participate in activities enjoy them. These need to be expanded to include all areas of the home. The home encourages autonomy and choice. In general residents enjoy the food and drink which is provided. However, the needs of residents who are underweight or overweight are not consistently understood and catered for. EVIDENCE: Service users on Jorvik wing were observed enjoying a sing-a long with the activities organiser. Questions were asked about particular pieces of music and service users were conversing with each other and the organiser in a discussion type forum. The staff on Ebor wing felt that more activities were needed. Currently there is one organiser who works 20 hours per week, the home have a mini bus available for trips but currently neither the handyman nor the activities organiser are insured to drive. Therefore it is up to the deputy manager to drive the minibus. In discussion with the activities organiser and manager it was evident that the home is hoping to employ another activities organiser who will be able to drive. This will also ensure that all residents are offered the same opportunity regarding activities. Staff complete social history and likes and dislikes regarding the activities, however, it would be beneficial if the organiser could contribute to the care plan when a resident has participated in an activity. South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 13 The home does have entertainers in the home and at Christmas time carol singers and local school children will be visiting. The activities organiser is keen to develop her skills further and would like to attend specific training in this area. The home offers religious services on a regular basis for residents to enjoy. The home promotes autonomy and choice. One resident said “anything I want I get, I can do what I want”. Residents are able to get dressed, go to bed and have meals when they wish. Evidence of residents having personal possessions in their rooms was observed and staff were clearly asking residents their views and opinions on daily activities. Residents on the mental health unit looked comfortable in their environment, advocates were available and family members could discuss autonomy issues with the staff. Both nurses in charge on this unit were keen to promote independence and choice. Mealtimes were observed and discussed with the catering staff and care staff. Beef casserole and vegetables was served at lunchtime and residents were seen enjoying this. One resident said “the food is good and the staff are good”. The chef did state that two frozen vegetables were used and fresh vegetables are infrequent. The portion sizes were adequate and residents could sit in a congenial setting to eat. Staff needed to give assistance to some residents who could not feed themselves. The kitchen area was examined which was kept clean and food was stored correctly. The head chef raised the issue that sometimes food is returned untouched on a plate, this is then thrown away without identifying who this belonged to and the rationale for not eating this particular food. The chef stated that some residents order salad and sandwiches on a regular basis. The chef is unaware which residents are underweight or overweight and which have specific dietary needs. Currently the chef will put cream in everybody’s porridge for example, as he is uncertain as to who needs it. There is extremely poor communication between the catering staff and care staff, regular meetings should take place to identify how individual needs can be met. The chef needs to be more accessible to staff and residents. The care staff should have a clear plan in place to address the needs of a resident who is underweight or overweight, this should be monitored and checked on a regular basis. South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home have systems in place which promote service users’ well being, and foster a safe and caring environment. EVIDENCE: The home have a robust adult protection procedure in place which includes whistle blowing. The manager is aware of the action to take when an allegation of abuse occurs. This has previously been discussed in detail. Four senior carers and six carers stated they had received training in this area. One registered nurse was waiting to have POVA training, but was aware of how to look after vulnerable adults. Staff were knowledgeable in the different types of abuse and the appropriate action to take. Service users spoken with said they felt happy and safe in their home. South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22 & 26 Service users were happy in their environment. However, aspects of the home need improving. Generally the home is clean and reasonably maintained. EVIDENCE: A tour of the premises took place. The manager is aware that elements of the environment need to be improved. Some redecoration had taken place and carpets in certain areas had been replaced. The layout of the home is suitable for its stated purpose. A gardener has been employed and the gardens look tidy and well maintained. This has improved since the last inspection. The home employ a maintenance person on a part time basis and they are hoping to expand this further. The home have previously had an environmental assessment, this was not available at the inspection but the Manager stated she would forward a copy to the CSCI. Grab rails, hoists, assisted toilet and baths were in place. The doorways were accessible for wheelchairs and the call bell system was adequate. South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 16 Both wings-the equipment was stored inappropriately, for example under the stairs wheelchairs, zimmer frames and walking sticks were stored. In the lift motor room by the kitchen, wallpaper, carrier bags, bulbs and cleaning products were stored. Moving and handling equipment was left in corridors throughout the home. The manager was made aware of this and must consider the hazard regarding fire safety which this is causing. Ebor Wing-The lounge is too small for the number of residents, there were 25 chairs and 27 residents. One resident was observed sitting on a stool, another lady was sat in an old ‘bucket’ type chair which was inappropriate (a discussion took place with the nurse in charge regarding control and restraint).Residents were in extremely close proximity to each other and it was difficult for staff to manoeuvre moving and handling equipment in this space. This was discussed at the last inspection and must be addressed. It was evident that other chairs were available in the corridor, however as discussed with the manager the area of communal space remains insufficient. The sluice room was inspected this was dirty with the floor marked with brown stains. The commode pots and containers stored in this room need a thorough clean, and the material that the pipes have been ‘boxed’ in with was cracked and broken and needs either repairing or replacing. Jorvik Wing-The sluice room though tidy had an extremely strong smell of urine which was present as soon as the door was open, this must be eradicated immediately. The home have a clear infection control policy in place which includes a workbook. Staff spoken with knew how to wash their hands correctly and when to use gloves, wipes and aprons. Staff on Jorvik Wing did say they were only allowed a certain amount of gloves and dry wipes per day. The manager had taken steps to increase this to ensure residents needs are met regarding personal care. Different colour skips were available for the use of soiled and non soiled linen. The laundry room was inspected which had an adequate number of machines and tumble driers in place. However, it was noted that these vibrated when in use. The home need to ensure this does not cause any health and safety risk to the staff. Staff in this area were aware of the correct temperature to use and disinfecting cycles were available. One issue which arose was the rotary iron, this has been out of order for 5 weeks. The manager must endeavour to get this replaced as soon as possible. Even though the environment needs improving residents spoken with felt happy and safe and enjoyed living in the home. South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 28 Residents needs can be met through appropriate staffing levels and care provided by competent staff. EVIDENCE: The staffing levels in the home are adequate. Residents spoken with felt their basic needs could be met. Ebor Wing (mental health)-two registered general nurses and eight carers for up to 49 residents were on duty over two floors. Currently there is no Head of Unit, and one RMN who works permanent nights. The manager has addressed this and over the next few months a Head of Unit will hopefully be employed. This person should be a registered mental nurse which will be extremely valuable to the unit. Observations on this Wing showed that there were sufficient staff, one registered nurse stated she had little mental health experience and was in charge of the Wing during the inspection. However, access to the Community Mental Health Team is available. Jorvik Wing (general nursing)-three registered nurses were on duty with nine care staff for up to 53 residents covering two floors. One senior sister was off sick, the home also employ overseas nurses and care staff due to difficulties recruiting locally. Staff morale was good and residents did not have to wait long before a call bell was answered, residents commented positively on the numbers and skills of the staff. South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 18 The manager is aware that vacancies in activities, maintenance and Head of Unit need to be filled. The manager is supernummary and the deputy has two supernummary days per week. The home encourage staff to undertake NVQ training. Currently there are 21 staff who have completed an NVQ Level 2 or above, out of 54 care staff. This equates to 39 which is a good achievement. The home are keen to have more assessors available to ensure further NVQ training is offered to new staff. South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33,35 & 38 Residents in the home feel confident that they can discuss concerns with the manager and her deputy. The home have developed a good quality assurance system and residents financial needs are met. The health and safety aspects of the home are not properly maintained which may put residents at risk. EVIDENCE: The registered manager is a general nurse who has recently completed a diploma level course in mental health in older people. This has given her a greater awareness and understanding of individuals with mental health needs. This is beneficial especially when assessments are undertaken by herself and the deputy (neither of which are registered mental nurses). The manager is professional and friendly with a pleasant disposition. Staff in the home feel she is approachable and promotes an open culture. Residents spoken with felt they could discuss issues with her and that action would be taken if necessary. The South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 20 manager is aware of how to meet individual needs within the philosophy of the home. Quality assurance systems in the home were inspected. A satisfactory policy is in place which details surveys sent to residents and relatives to ascertain their views regarding the service they receive. Residents and staff meetings take place and monthly audits relating to care plans, medication and the kitchen area take place. Four Seasons Healthcare analyse the findings and action is taken by the manager to address any issues identified. The manager of the home has informal discussions with staff and residents on a daily basis. Service users’ finances were inspected and the home have personal allowance accounts. Records of all transactions were available and the home has an account with the local bank where service users are able to deposit and withdraw their money. This is a non-interest account. Four Seasons Healthcare act as corporate appointees for seven residents, and the administrator audits bank statements and the balance goes to head Office. There are some residents who have a negative balance, the home sends letters out to the respective individuals. The home should avoid this wherever possible. Health and safety was inspected in the home. Training relating to fire safety, moving and handling, COSHH and protection of vulnerable adults take place. Records confirmed this to be the case. A selection of certificates were inspected including the following; the servicing of passenger lifts, portable appliance testing, electrical wiring, hoisting equipment, fire alarm and emergency lighting tests and water temperatures. Boilers had been serviced, window restrictors were in place and systems for the safe disposal of waste was in place and evident in the home. At the inspection two immediate requirements were issued relating to health and safety. On Ebor Wing the radiators did not consistently have appropriate guards on them. Specifically the corridor radiators which included the radiator near the fire exit where the top of the radiator had brown stains on it and the width of the radiator was not guarded. There was approximately an 8 inch gap where service users could easily put their hand in and touch the very hot radiator and potentially burn themselves. During the inspection residents were observed wandering around this area. This must be made safe as a matter of urgency. The water temperatures in the home had been tested on 22nd November 2005. It was identified at the inspection that temperatures ranged from 43 degrees centigrade to over 50 degrees centigrade. This is unacceptable, some of the hot water temperatures were in residents rooms. Appropriate action has not been taken and this issue must be addressed. South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 21 A requirement was made regarding the safety of the fuse box on Jorvik wing. This was found to be unsafe as the bottom door did not have a secure lock. This was a concern as there was a warning notice relating to voltage of the fuse box. This had been taped up, but this was not adequate. The above issues were discussed with the manager as the health and safety of residents must be paramount in the home. South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 22 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 1 x x 1 x x x 1 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 x x 1 South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 23 YES 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 OP15 Regulation 16(2) Requirement A robust communication system between the catering staff and care staff must be implemented to ensure service users nutritional needs are met at mealtimes Ebor Wing-the home must ensure there is adequate and suitable lounge space for all service users (previous timescale 11/07/05 not met) Equipmentwheelchairs/hoists/walking sticks must be stored in a designated area to prevent a fire hazard Yorvik Wing sluice-the strong smell of urine must be eradicated Ebor Wing sluice-the floor must be thoroughly cleaned to remove brown stains. The containers/commode pots must be thoroughly cleaned. The boxed area covering the pipes must be repaired or replaced . Yorvik Wing fuse box-the lock DS0000027981.V266279.R01.S.doc Timescale for action 04/12/05 2. OP19 23 (2) 01/03/06 3. OP22 23(2) 01/03/06 4. OP26 13(3) 04/12/05 5. OP38 13(4) 04/12/05 Page 24 South Park Version 5.0 6. OP38 23(2) must be replaced and the box kept locked to ensure no service user is at risk Ebor Wing-guards must be fitted to all radiators where gaps have been identified (as a priority the radiator near the fire exit). This radiator must also be cleaned thoroughly. Immediate requirement issued. Water temperatures- must be maintained within the expected parameters(approximately 43 degrees centigrade).Action must be taken when temperatures exceed normal. Immediate requirement issued. 04/12/05 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. 3. Refer to Standard OP12 OP22 OP28 Good Practice Recommendations The activities organiser should contribute to service users care plans The home should forward a copy of the environmental assessment to the CSCI Care staff should have achieved an NVQ Level 2 or equivalent be December 31st 2005 South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 South Park DS0000027981.V266279.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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