Inspection on 11/01/07 for South Park

This inspection was carried out on 11th January 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

South Park 19/09/07

South Park 25/05/06

South Park 01/12/05

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 Key Unannounced Inspection 11th January 2007 09:00 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.V326804.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. South Park DS0000027981.V326804.R01.S.doc Version 5.2 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 www.fshc.co.uk Ringdane Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Post vacant Care Home 102 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) 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.V326804.R01.S.doc Version 5.2 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. 25th May 2006 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 current scale of charges for local authority placements is £473-£483, and for those who are self funding £520-525. Additional charges are made for the hairdresser, chiropodist, aromatherapy and for newspapers/magazines. 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 Jorvik is for general nursing care. The home also offers day care for up to 8 service users. South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection of the service took place on Thursday 11th January 2007. Prior to the visit a pre- inspection questionnaire was completed along with service user surveys and comment cards from relatives and healthcare professionals. One inspector spent 8.5 hours at the home, during this time service users, relatives and staff were spoken with. Care practices were observed including the lunchtime meal and discussions took place regarding outcomes for service users, and staffing issues. A sample of policies and procedures were also examined. Evidence relating to all of the key standards was obtained either prior to, or during the visit. Eighty service users are currently residing at the home. Outcomes for service users have started to improve on both the general nursing unit and the dementia unit. These include care practices, mealtimes, communication and health and safety issues. The new manager has developed new ways of working and begun to put in place systems to sustain good standards of care which should have a positive impact on the service users. The manager, deputy and Four Seasons are aware of the improvements that need to be made in order to progress the service over the next 6-12 months. This is a huge step forward and is extremely encouraging. The main issue that needs to be resolved is the poor environment for both service users and staff. What the service does well: What has improved since the last inspection? South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 6 Service users and staff have benefited from a new manager been appointed. Standards in the home have improved and risks to service users have been minimised. Two Heads of Unit have been appointed for the general nursing and dementia care areas. This should give some stability and consistency to the service users and staff. A permanent chef has recently been appointed. Service users commented positively on the improved choice and variety of food, and in particular there is an improved atmosphere in the dining area on the general nursing unit. A robust communication system has been implemented by the manager. Staff are more aware of how to communicate appropriately with service users and healthcare professionals, and they are aware of the changing needs of service users which is also reflected in the care plans. The manager has started to implement Four Seasons quality assurance system to obtain the views and opinions of service users and their relatives. Further audits on documentation have also taken place to ensure a good standard is being obtained. Staff have received further training in safe guarding adults. The manager and deputy are keen to develop a positive and open culture amongst staff. This helps to identify any concerns regarding service users and helps to clarify the action needed to minimise any risks. Staff are starting to complete a robust induction programme which highlights care practices, training needs and health and safety issues. This will help to develop consistency amongst staff and ensure all staff are working to the same level, which will be beneficial to service users. Risks to service users through high water temperatures have been reduced. whilst the system clearly needs improving no further concerns have been raised during the site visit. Service users are having their nutritional needs assessed using an appropriate assessment tool. Care staff and catering staff have a better understanding of how to identify if a person is under or overweight and the action needed to resolve this. The manager is receiving an improved level of support from the regional manager and the management team at Four Seasons. This has had a positive impact on the outcomes for service users. South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 7 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. South Park DS0000027981.V326804.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 South Park DS0000027981.V326804.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): 3 (Standard 6 is not applicable) Quality in this outcome area is adequate. Service users have their needs assessed in a satisfactory manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Assessments were examined on both units. Currently the manager or deputy of the home visits a potential service user either at home or in hospital to complete the initial assessment. These were completed satisfactorily and covered social, nursing, medical and mental health needs. Not all sections were completed though a general picture of the needs of the individuals could be obtained. A discussion took place with the new RMN on the dementia unit regarding who carries out the assessments. It is envisaged that the assessments will be carried out by the Head of Unit once they are established in the home. South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 10 The new Head of Unit in the General Nursing area does need to become more familiar with the information in the assessments, however as this person has recently commenced in this role this will need to be reassessed at the next inspection. South Park DS0000027981.V326804.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 & 10 Quality in this outcome area is adequate. Service users have their needs recorded and these are generally met. Privacy and dignity is maintained and staff have a good understanding of the medication and nutritional assessment system. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of service user files were inspected, there has been an improvement in the standard of the documentation since the last inspection and care plan auditing has been taking place. Care plans had assessments in place for moving and handling, risk assessments, the prevention of pressure sores and the risk of falls. Individual care plans identified the needs service users had and these were completed satisfactorily. It was evident that reviews and evaluations of care plans had not taken place on a regular basis, and in some instances since last June. The Head of the dementia unit is aware of this and is working his way through each plan to ensure this is resolved. A discussion took place regarding the use of bed rails on the dementia unit, it was not always South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 12 clear in the care plan as to the rational for using them. This should be reviewed. The home has progressed well with undertaking nutritional assessments. Staff have a greater understanding of how to care for service users who are either under or overweight. A nutritional tool is consistently used, along with weight charts, and information is obtained through the community dietician. On one occasion a service user had been given a pureed diet, however there was no specific care plan for this and the Head of Unit was unsure of the rationale for this. This was discussed with the manager of the home. The home are also more aware of how to use pressure relieving equipment. Input from healthcare professionals was evident, comment cards were received from GPs, and evidence of hospital appointments, visits from the chiropodist and dentist were confirmed in individual files. The chiropodist was observed visiting service users on the dementia unit during the site visit. One comment was made regarding ‘nail cutting’ and whether this had to be paid for as an extra via the chiropodist. The manager confirmed that an NHS and private chiropodist is available, and staff will cut nails as part of basic care practices unless this is contra-indicated. Staff were observed in both areas treating service users with respect and dignity, a good rapport was evident between staff and service users and the whole atmosphere of the home has improved since the last inspection. Staff were observed knocking on doors prior to entering and vacant and engaged signs were evident in the toilet and bathing areas. Service users looked clean and tidy, visits to the hairdresser were available and those service users observed in bed looked comfortable and well cared for. The medication system was examined in both areas, registered nurses are responsible for administering medication and audits of the system take place on a regular basis via the manager. Any errors found are dealt with accordingly. Staff had a greater awareness of safety surrounding use of the medication trolley, this was observed. Medication charts were checked and these were found to be completed correctly. In the general nursing area the new Head of Unit was unsure of how to dispose of controlled drugs, although the equipment needed was available. The controlled drugs book in this area was completed effectively with two signatures evident when administering a controlled drug. The fridge temperatures should be taken daily, this does not consistently happen. The medication room on the general nursing unit is very small with a boarded up window, plaster is coming of the walls and the whole area needs refurbishing. South Park DS0000027981.V326804.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 & 15 Quality in this outcome area is adequate. Service users have access to some activities with autonomy been encouraged. Service users meals have improved with a greater understanding of individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Currently the home have one activities organiser and are in the process of employing another person. Therefore at present there is not a full activities programme for service users to enjoy. Comment cards and surveys confirmed that more activities are needed. It is evident that this is extremely important for people with dementia and general nursing needs. Service users were observed watching television, listening to the radio or reading magazines and books. Staff were observed having one to one discussions with service users which clearly both parties enjoyed. Service users did comment that some activities were available over Christmas and the Head of Unit are keen to develop this area further. Visitors are welcomed into the home at any reasonable time. This was confirmed in the visitors book and was observed during the visit. Service users South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 14 spoken with confirmed they could get up when they want and go to bed when they choose. Service users were observed in different parts of the home i.e. lounge, conservatory, dining area and in their own rooms. Individual care plans discussed daily routines and specific preferences. Since the last inspection a new permanent chef has been appointed, he started ten days ago, and whilst this Standard will be assessed in more detail at the next visit, it is evident that some changes have already taken place which have had a positive effect on service users. The menu has changed and at least one fresh vegetable is available each day, more home cooked food is on offer and the chef is developing an effective communication system with the care staff. Observations confirmed that the chef talks to service users about the meals provided and the atmosphere on the general nursing unit was more relaxed at lunchtime and calmer. Service users were observed enjoying a range of food with a choice of drinks. Material napkins were available which were given to the service user just prior to the food been served (though a few people had to use blue plastic aprons). The chef is starting to monitor the food that is returned to the kitchen and food hygiene training has been undertaken. An understanding of how to fortify food, deal with pureed food to ensure the nutritional value is maintained and recognise the signs when someone is losing weight are now in place. Plate guards are available and specialised cutlery is used when needed. One observation was that salt and pepper pots are not used, instead disposable packets are available. The environmental health officer had raised concerns regarding the kitchen area and the manager has worked hard to rectify these. No concerns were raised during the visit regarding the storage of produce. South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. Service users are more confident about raising concerns and they feel safe in their environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new manager is keen to develop an open culture for service users and staff where concerns can be raised and acted upon. Any adult protection issues can now be brought to the attention of the deputy or the manager and dealt with in line with the current procedure protecting the relevant individuals. The home have a complaints procedure in place with relevant timescales. No formal complaints have been raised since the last inspection though a concern has been noted and actioned accordingly. Service users spoken with said they were happy to speak to staff, and staff felt more positive about sharing any issues with the new manager and they confirmed action would be taken in a prompt manner. Some concerns were raised in the comment cards and surveys, these related to lack of activities and some care practices. These were discussed with the manager. One GP had identified some areas regarding communication which needed improving. The manager has dealt with this and the situation is improving. South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 16 One adult protection referral has recently been made regarding care practices, though following an investigation the abuse aspect of the issue was not substantiated, though concerns regarding effective communication were evident. Staff have undergone protection of vulnerable adults training which was confirmed in discussion with staff. This is an ongoing training programme which will ensure consistency amongst staff if they need to report a potential abuse situation. It must be noted that due to the recent change in management further evidence is needed to ascertain the improvements that have been made in this area. Specifically regarding the culture of the home. This will be further examined at the next inspection. South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 17 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): 19,22 & 26 Quality in this outcome area is poor. Staff care for service users in a poor environment, where the call bell system is not effective and there is a greater understanding of infection control needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is split into two units, one for general nursing and one area for dementia care. A refurbishment is clearly needed and though maintenance staff keep the area hazard free, the logistics of staff accessing service users and being able to fully meet their needs is compromised by the poor environment. The home is planning a refurbishment though no definite timescale has been given for this. On the general nursing area there is a ground, 1st and 2nd floor which need to be staffed adequately. There are currently twelve service users in bed and on South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 18 one occasion a call bell on the second floor was pressed and it took the staff seventeen minutes to respond. The service user needed the toilet and this time delay could have been detrimental to the service user concerned. This delay in responding is not acceptable and was discussed with the Head of Unit and manager of the home. In the lounge area on the general nursing unit it was evident that the call bell system is not accessible to all service users, this needs to be rectified. It was evident during the visit that some call bells could have been answered quicker. There have been some improvements in the environment, for example a new carpet in the conservatory and the smell of urine in this area has been reduced. The dementia unit has two floors which again makes it difficult for the Head of Unit to supervise. There remains insufficient communal space which has been highlighted at previous inspections and consideration needs to be given to the environmental design of this area to improve the outcomes for service users. This was discussed with the Head of Unit. The sluice areas were examined and on the 1st Floor on the general nursing unit the sluice was open. A bolt was available on the outside though this could pose a risk to someone who is in the room. A more secure system is needed to ensure the safety of the service users and staff. On the dementia unit (1st Floor) the sluice room door was left open. Both these rooms had a strong smell of urine which needs to be eradicated. Some staff have completed infection control training, though other staff have not undertaken this for over 12 months. The laundry room was inspected and staff felt there were sufficient washing machines and driers. There is only one door to bring soiled clothes into the laundry and to take clean clothes out. Staff need to ensure there is no cross contamination. Some comments from relatives were that clothes often go missing. Staff spoken with felt this was usually when clothes had not been named correctly, on one occasion a skirt had been torn by accident. However this was dealt with appropriately by the manager. No service users complained about any offensive smells in the home. An outbreak of the Norwalk Virus has previously occurred, the infection control nurse was informed and the correct precautions were taken. New systems for dealing with different types of laundry have now been put in place. South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 19 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 & 30 Quality in this outcome area is adequate. Service users are cared for by suitably trained staff, though these are not always deployed correctly, partly due to the environment. Service users are generally protected by the home’s recruitment procedure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home currently has eighty service users, these are divided between the general nursing and dementia care unit. They are staffed separately. The manager and deputy are supernumerary and some hours are given to the Heads of Unit for supernumerary time. Staffing levels are regularly reviewed, though as previously discussed the deployment of staff on the general nursing unit needs to be revisited to ensure individual needs can be met. During the visit there were adequate staff on duty. Staff spoken with did not feel they were understaffed. Service users were observed in the communal areas speaking with staff though the 1st and 2nd floor of the general nursing area did not appear to have many staff available, though twelve service users were either in bed or sat in their chair in their rooms. Both Heads of Unit have recently commenced in this role (1-2 weeks) and therefore it is difficult to assess in detail the impact they have had to the home. Clearly the home needs some stability and staff need to feel confident in South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 20 the Heads of Unit and use them as a role model. The Head of the Dementia unit is an experienced RMN with a sound knowledge of the care this client group needs. Staff were observed approaching him in an open and positive manner and the atmosphere was pleasant on both floors. The Head of the general nursing unit has experience of working in this unit and needs to develop her confidence and skills in a management capacity. Care staff have undertaken NVQ Level 2 training, the home needs to develop more staff in this area to ensure there is a consistency in approach and staff are working to the same standard, particularly in relation to care practices. Four Seasons have developed a detailed induction book for new care workers, this is equivalent to ‘Skills for Care’. This is usually completed with in the first twelve weeks. Standards covered include; the principles of care, understanding the organisation, health and safety, effective communication, protection of vulnerable adults and developing as a worker. The new employee has different activities to complete which are then signed off by a mentor. Staff spoken with are currently completing these though as this has recently been introduced the impact of this style of induction cannot be evaluated at this stage. In addition to this core booklet there are specific topics which can be completed within eight to fourteen weeks, for example death and dying. Recruitment procedures were discussed and examined. When a vacancy arises an advert is placed and application forms are completed. Two references a CRB and Protection of vulnerable adults check is obtained prior to employment. Two staff files were examined, on one file all relevant information had been obtained, though on the other (non caring position) the CRB had been sent for but not obtained and only one reference had been received. The member of staff had completed a POVA check and was aware that he could not work with a service user unsupervised. This was discussed with the manager who was aware that the 2nd reference needed to be obtained. South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is adequate. Service users have benefited from having a new manager and their views are being sought regarding the care they receive. Finances are dealt with appropriately and generally service users are safe in their environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new home manager is a registered nurse with previous experience of running a large nursing home. She is in the process of applying to become the registered manager of this home (as was her position before). A range of improvements have been made since she commenced at this home in September 2006. She is dynamic, progressive and aware of how to improve the service and the outcomes for those using it. She is supported by the deputy and regional manager and has already implemented systems to ensure service users can voice their views and opinions. South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 22 The home have a quality assurance system in place (called Clinical Governance), this has recently been implemented and service users questionnaires will be sent out in due course. Regular staff meetings have commenced and the feedback from these is encouraging. More robust and effective communication systems have been put in place and auditing of care plans, medication systems, kitchen, accidents and pressure sores are evident. These systems should help to raise standards in the home. Relatives are now involved with discussions regarding care of their family member and they are communicated with on a regular basis. The manager is aware of the importance of seeking views and opinions of all service users to ascertain the quality of the service provided. This will also be beneficial when Home’s are completing the annual quality assurance assessments from the CSCI. Service users finances were discussed with the administrator. A personal allowance account is available which is discussed with new service users and their family when they enter the home. Relatives can bring money into the home for hairdressing, chiropody, toiletries etc. This is recorded and a receipt is given (this was observed during the visit). A limited amount of money is kept in the home but transactions checked were completed correctly. The home is looking into having individual ‘purses’ or ‘wallets’ for each service user. Staff currently receive mandatory training in fire safety, moving and handling and health and safety. During the day there is always a qualified first aider, though this is not the case overnight. Individual training files are kept in the home and the manager is keen to ensure infection control training, POVA and first aid is kept up to date. Staff are aware of the action taken if mandatory training is not attended. During the visit fire doors were kept closed, emergency lighting was evident and staff were aware of the action to take if the fire alarm sounded. (This occurred during the visit). On the dementia unit whilst all the service users room doors were closed it was evident that the new Head of Unit needed to be more aware of the importance of not propping doors open by unauthorised means. Staff were observed using hoists to move service users, this was done in a competent manner and staff confirmed training had been received. Information in the pre-inspection questionnaire discussed health and safety certificates and the contracts for moving and handling equipment. Water temperatures which have previously been high were tested, these were found to be within expected parameters. Although records did show that some had been too low. Staff have started to record water temperatures prior to a service user getting into a full immersion bath, this was confirmed by staff. Radiator guards were in place and window restrictors. Service users spoken with said they felt safe in the home. South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 1 x x 1 x x x 1 STAFFING Standard No Score 27 2 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 2 South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 24 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. 2. Standard OP7 OP19 Regulation 15 23 Timescale for action Care plans must be reviewed and 11/01/07 evaluated on a regular basis. The environment must be 11/02/07 refurbished to improve conditions for service users and staff. A timescale for commencement and completion of the refurbishment must be forwarded to CSCI. All areas of the home used by 12/01/07 service users must have an appropriate call bell system in place. Staff must answer call bells in a prompt manner. Sluice rooms must be kept 11/02/07 locked when not in use. Strong urine smells in the sluice must be eradicated. Two written references must be 11/01/07 obtained prior to staff commencing employment. The home manager must be 11/04/07 registered with the CSCI A qualified first aider must be 11/03/07 available overnight Requirement 3. OP22 18 4. OP26 13 5. 6. 7. OP29 OP31 OP38 19 9 13 South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 25 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 OP3 OP9 Good Practice Recommendations The RMN on the dementia unit should be undertaking initial assessments of service users. The fridge temperature in the medication room should be taken daily. Staff administering medication should be aware of how to dispose of controlled drugs correctly. More activities are needed on the dementia unit. Staff should ensure the correct material napkins are used for service users at mealtimes. Salt and pepper pots should be made available for service users at mealtimes . Staff should ensure they are up to date with infection control training A review of the deployment of staff in the general nursing area should take place. Further care staff should try to achieve an NVQ Level 2 or above. 3. 4. OP12 OP15 5. 6. 7. OP26 OP27 OP28 South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 South Park DS0000027981.V326804.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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