Inspection on 14/07/06 for South Park

This inspection was carried out on 14th July 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

South Park 10/07/07

South Park 07/02/06

South Park 20/10/05

South Park 16/03/05

South Park 20/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 South Park 10 & 11 Park Drive South Gledholt Huddersfield West Yorkshire HD1 4HT Lead Inspector Karen Summers Key Unannounced Inspection 14th July 2006 09:30 South Park DS0000050141.V306744.R01.S.doc Version 5.2 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 DS0000050141.V306744.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 Adults 18-65. 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 DS0000050141.V306744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Park Address 10 & 11 Park Drive South Gledholt Huddersfield West Yorkshire HD1 4HT 01484 315551 01484 315551T/F compass.care@ntlworld.com 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) Compass Care Homes Ltd Mrs Lesley Scott Care Home 10 Category(ies) of Learning disability (10) registration, with number of places South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: South Park is a care home providing accommodation and personal care for ten people subject to varying degrees of learning disability. The business is privately owned through a limited company. The accommodation consists of two linked dormer bungalows. All the bedrooms are for single occupancy and there are two communal lounges and dining areas. There is a garden with a decking area to the rear and a small amount of off road car parking to the front of the property. The home is sited adjacent to Greenhead Park in a residential suburb of Huddersfield. There are some shops within walking distance and good transport links into the centre of the town. Fees at the home start at £ 367.72 - £940.31 per week. Items not covered by the fee include: Hairdressing and toiletries. South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to a key inspection, which included an unannounced site visit on the 14th July 2006, and the duration of the inspection was 7.25 hours. There were 10 service users in residence on the day. Mrs Lesley Scott, manager, was present throughout the inspection. The following areas were looked at and have been used in the production of this report; a sample of records, care plans, medication, individual discussion with five service users, two members of staff, tour of the premises and document reading. To reflect the views of those who use the service, satisfaction questionnaires were sent to: 10 service users, none were returned; 13 relatives/ advocate/ friend, 8 were returned, and GP’s and district nurses, none were returned. The inspector would like to thank those who contributed to the inspection process, and also thank Mrs Scott, her staff and service users, for their time and hospitality on the day of inspection. What the service does well: What has improved since the last inspection? The service user’s care plan includes all aspects of the service users personal care needs. South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 6 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. South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. No service user moves into the home without having had his/ her needs assessed and been assured that those needs will be met. EVIDENCE: The home has not had an admission for several years however, the manager confirmed that a community care assessment would be carried out, and the service user would be invited for visits to the home, and this would include an overnight stay. The manager would also carry out her own assessment to ensure that the home could meet the service users needs. South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users personal and social care needs are set out in an individual plan. They make decisions about their lives with assistance as needed, and are supported to take risks as part of an independent lifestyle. EVIDENCE: The care records were of a good standard, and included risk assessments and the personal care needs. The daily record was an account of the care given that day, and it also included social care that the service user had taken part in, and any untoward incidents. There was evidence to suggest that the documents had been reviewed and updated. South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Service users take part in appropriate activities, and are part of the local community. Service users are encouraged to maintain contact with their family and friends. Service users receive a varied diet that takes into account the dislikes and dietary needs of the service users. EVIDENCE: Service users are encouraged and supported to develop and maintain independent living skills, and also participate in a wide range of social and recreational activities. Activities include trips out of the home to places of interest, e.g. York, Blackpool lights, the zoo, the Lakes, train rides, visits to the local public house to play pool. All service users go on a holiday, and their time away from the home depends upon their assessed needs and the preferences of individual service user. Two of the service users talked South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 11 enthusiastically about their holidays, and how they were looking forward to their next holiday later this year. The home has transport that will take wheelchairs, therefore those service users in need of wheelchair assistance are able to go out and live an independent life as possible. Service users were relaxed, and looked well cared for, and staff were observed supporting people in a caring and sensitive manner. The menu was varied and took into consideration the likes and dislikes of service users. South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 - 20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional needs are met. Medication housekeeping is of a satisfactory standard. EVIDENCE: Each service user has a plan of care that they have, where able, taken part in, records how they prefer their daily personal needs to be met. There was also evidence to suggest that the information had been reviewed and updated. One of the service users said, that they liked the staff and that they were always looked after. The service users’ records indicated a good level of contact with the primary health care team and a full range of medical services. Some service users receive specialist medical care on a regular basis. Staff that administers medication have had training, and the medication and records that were audited were correct. The room where the medication was stored was warm, and at periods during the day the temperature changed in South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 13 this room. The temperature where medication is stored should not be more that 25˚C; therefore you are advised to monitor and record daily, the temperature of the room. South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. To ensure that service users and their relatives/ advocated have the opportunity to make a complaint if they so wish, the complaints procedure should include the information as specified by the standard. Service users are protected from abuse. EVIDENCE: There is a very basic complaints form, which does not include the stages of, and time scales for the process, and does not give the information as specified in the standards. The document is also on the reverse of a feedback form, for visitors to complete about their experience on visiting the home. The document must include the information in regulation 22, and standard 22. There is a whistle blowing procedure, and staff have abuse awareness training. The home needs to have a more up to date Kirklees Protection of Vulnerable Adults Policy. Six relatives/ advocates questionnaires stated that they were aware of the complaints procedure, although they had never made a complaint. Two questionnaires stated that they were not aware of the complaints procedure. South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is in a good state of repair and decorative condition, and service users’ individual needs are met in a comfortable and homely setting. The premises are clean and systems are in place to control the spread of infection. EVIDENCE: Generally the home is in a good state of repair and decorative condition. A specialised bath, and bathroom suite has been ordered for the down stairs bathroom, which is soon to be upgraded. Service users rooms were individualised with personal belongings, and reflected the personalities and tastes of the service users. The premises were clean and systems are in place to control the spread of infection. The service user satisfaction questionnaires commented that the home was always clean. South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing levels and skill mix were sufficient to meet the number and needs of service users. Service users are supported and protected by the home’s recruitment practices. EVIDENCE: The staffing levels and skill mix were sufficient to meet the number and needs of service users. Relative’s questionnaires stated that there were always sufficient numbers of staff on duty. One member of staff has an NVQ level 2, and six other carers are hoping to start the qualification in the next two months. The registered person operates a thorough recruitment process, ensuring the protection of service users. Staff confirmed that they had had induction training within 6 weeks of their employment, and were able to say what the induction included. The information was also recorded in the staff training files. South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The registered manager is of good character and competent to manage the home. Until all staff have had a fire lecture, staff and service users health and safety could potentially be at risk. Without the use of service users surveys, and the outcomes of the surveys being published, service users and their relatives do not have the evidence to show that the home is run in their best interest. EVIDENCE: Fire alarms are tested weekly and recorded. The fire facilitator left in January this year, and according to the staff training records staff have not had any fire lectures. The manager said that staff had had training at the staff meetings that takes place approximately every two weeks; unfortunately the lectures South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 18 had not been recorded. All staff are requested to have two fire lectures a year, which are recorded. Following the site visit the manager booked a fire-training day for all staff. A member of staff has also been booked on the fire facilitator course, and then they will be able to give further training to the staff at the home. In relation to quality assurance, the provider completes a monthly report on the conduct of the home. On the reverse of the complaint forms, which are kept in reception, there is a feedback form that asks visitors about there experience at the home. Unfortunately none of the forms are ever completed. The manager said that she is in the process of producing questionnaires that aim to seek the views of service users and their relatives/ advocates. The manager also said that the outcome of the surveys would be published. Residents have monthly meetings where their views are recorded, and any action monitored. Minutes are recorded at the meetings. In addition to this a newsletter is published which includes forth-coming events, at various times throughout the year. South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 X 3 3 X 2 X 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 1 X South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 20 NO 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 YA22 Regulation 22. 23.-(4)(d) Requirement The complaints procedure must include the information in this regulation and standard. The registered person shallmake arrangements for persons working at the care home to receive suitable training in fire prevention. (Conformation received following the site visit, that a training sessions for all staff has been arranged for 19/07/06) Timescale for action 29/08/06 19/07/06 YA42 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 YA20 YA23 YA32 Good Practice Recommendations Medication should not be stored above 25˚C, you are advised to monitor daily the temperature of the room where the drugs are stored. The Kirklees Protection of Vulnerable Adults Policy should be replaced with up to date documentation. 50 of care staff should have an NVQ level 2 or equivalent. DS0000050141.V306744.R01.S.doc Version 5.2 Page 21 South Park 4. 5. 6. YA37 YA39 YA42 The manager should complete the Higher National Certificate in Health and Social Care. Quality monitoring should take place that seeks the views of the service user and meets this standard. Staff should have fire lectures twice a year. South Park DS0000050141.V306744.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 DS0000050141.V306744.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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