Inspection on 19/09/07 for South Park

This inspection was carried out on 19th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 11/01/07

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 19th September 2007 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.V333756.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.V333756.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) Sarah Paskett 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.V333756.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. (No longer applicable) 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. Date of last inspection 11th January 2007 Brief Description of the Service: South Park Care Home is part of the Four Seasons Health Care Group. The Home has recently been refurbished and can now accommodate up to 82 older people who require general nursing care and mental health nursing care. The current scale of charges is £470-£670. Additional charges are made for the hairdresser, chiropodist, aromatherapy and for newspapers/magazines. Information regarding the service can be found in the statement of purpose, and enquiry forms are completed when a person visits the service for the first time. 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. South Park DS0000027981.V333756.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 Wednesday 19th September 2007. Prior to the visit an Annual Quality Assurance Assessment was completed and surveys were obtained from people using the service, relatives, GPs, specialist nurses and a number of staff. In preparation for the visit it was decided that use of an expert by experience would be beneficial along with one inspector. At the visit the expert by experience spent two hours on the general nursing unit (Jorvik) speaking to three people using the service regarding their views on a range of care issues. The inspector spent 6.5 hours observing practices on both the general unit and on the dementia unit (Ebor), discussing the progress of the service and how outcomes have improved since the last visit. A tour of the environment took place (due to the recent refurbishment) and records regarding care plans, medication, staff training and complaints and protection were all inspected. The lunchtime meal was viewed on both units and aspects of health and safety and quality assurance were discussed. People using the service discussed their daily activities along with the initial assessment that takes place when they are first admitted to the home. The manager and her team have effectively improved outcomes for people using the service. This was evident in the care being provided in an extremely pleasant atmosphere, the attitude and manner or staff, the reduced level of risk to people and the improved quality assurance system. What the service does well: What has improved since the last inspection? People are cared for by staff who have a pleasant attitude and manner and are competent in understanding individual needs. The standard of record keeping in the care plans has improved, regular reviews and evaluations take place, which ensures that current needs are being met. People are able to access staff effectively through an improved call bell system. South Park DS0000027981.V333756.R01.S.doc Version 5.2 Page 6 Staff have a greater understanding of how to maintain infection control procedures, the sluice areas are kept secure, and rubbish is disposed of appropriately. Staff are being monitored more effectively, regular audits of medication, care plans and health and safety take place this ensures that peoples needs are being met and any concerns are raised and dealt with. People on the dementia unit have pleasant communal areas to sit and eat in, this has greatly been improved with the changing around of the dining room and lounge area. 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.V333756.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection South Park DS0000027981.V333756.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, (Standard 6 is not applicable). Quality in this outcome area is good. People who may use the service and their representatives have the information needed to choose a home which will meet their needs. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Assessments are carried out prior to admission so that the manager can be sure the home is able to meet the needs of each person before offering a place. The head of unit on the general nursing side and on the dementia unit complete these assessments. Service users where possible, or those who act on their behalf are involved in the assessment which then forms the basis for a good plan of care. Some service users had visited the home before admission for day care, and so had the opportunity to decide whether home was right for them. For those whose capacity is affected by a mental illness, those who act on their behalf are invited to visit the home and ask any questions they wish South Park DS0000027981.V333756.R01.S.doc Version 5.2 Page 9 about the care of offer. The care manager is the person is funded through social services also undertakes an assessment which helps to inform the homes assessment. A range of assessments were inspected and these contained relevant and detailed information regarding health and personal care needs. South Park DS0000027981.V333756.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People who use the service experience good quality outcomes in this area. People have their health and personal care needs met, and privacy and dignity is well maintained. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People have their health and personal care needs met. Observations on both units showed people looking clean and well cared for. Five people discussed the care they receive. The expert by experience had positive comments from the three people he spoke to ‘staff are friendly’, another comment was ‘the staff know how to care for me’ and ‘staff have a good rapport with me and each other’. Care plans were examined and improvements in the reviewing and evaluation of care were evident. Risk assessments were in place relating to the risk of falls, nutrition, moving and handling and the use of bed rails. On one occasion a person was moved using equipment and this had not been updated in the risk assessment. However, when this was discussed with the South Park DS0000027981.V333756.R01.S.doc Version 5.2 Page 11 member of staff immediate action was taken to address this. Staff had a good understanding of how to meet nutritional needs and a discussion took place regarding intervention from the GP and community dietician in one particular case. Evidence of input from a range of healthcare professionals was evident in the care plans. Daily progress sheets were completed and a named nurse and key worker system was in operation. Privacy and dignity on both units was found to be well maintained and staff were observed liaising with people in a pleasant and confident manner. Suitable signage regarding engaged and vacant signs for the toilet/bathroom areas was available and staff were keen to maintain dignity. The medication system was inspected on both units. A robust system is in operation which reduces the risk of harm to people. New treatment rooms are evident on the general nursing unit and a safe storage area is available on the dementia unit. Five medication charts were inspected generally these were completed effectively. On the dementia unit on two occasions a stock balance of medication did not tally with the amount of medication left i.e. sodium valporate and madopar. There were also seven blister packs with medication in left on the side which should have been destroyed. This was discussed with the manager as clear disposal and record keeping is needed to ensure there is a clear audit trail. The controlled drugs book was checked and further medication training is planned. Following an audit of the system by the manager an issue with the storage of controlled drugs had been identified which was in the process of being addressed. South Park DS0000027981.V333756.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People who use the service experience adequate quality outcomes in this area. Whilst activities are offered this area needs further developing. The food and drink provided is appropriate and visitors are encouraged into the home where autonomy and choice is offered. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People do have access to a range of activities and there are designated organisers on each unit. There is an activities diary and staff are aware of individual needs. Relatives and residents have input into this through regular meetings. Recently trips to Rowntree Park and Burnby Hall gardens have proved popular. Bingo/dominoes/cards are available which was evident at the visit. Manicures and hairdressing are available which was confirmed by some people and trips into Acomb and spending time in the garden is encouraged. The home has a minibus though this was confirmed in the surveys returned, some people felt the minibus and garden area was underused. The manager is aware that the activities need to be developed further to ensure all needs are South Park DS0000027981.V333756.R01.S.doc Version 5.2 Page 13 being met. Visitors are welcomed at any time which was evident when speaking with people and also when examining the visitors book. Church services can be organised and individualised routines are encouraged. One person stated ‘I get up when I want to and go to bed when I want to’, another said ‘staff ask me what I would prefer to do i.e. bath/wash/shower’. The lunchtime meal was observed at different times on both units. The newly refurbished dining areas have had a positive effect on people, both rooms are light and airy with comfortable chairs and tables. Material napkins, glasses and suitable crockery were evident. In both areas the meals provided were of a good standard, the atmosphere has improved since the last visit and there is a relaxed and calm feel to both areas. The permanent chef was unavailable and an agency chef was in charge of the meals. He had a good understanding of how to ensure food is nutritious and was aware of how to cater for diabetics or those needing pureed food. Home baking was evident and staff were observed assisting people in a dignified manner. South Park DS0000027981.V333756.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People who use the service experience good quality outcomes in this area. People have their concerns listened to and acted upon appropriately in a safe and protective environment. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home have a robust complaints procedure in place. Everyone who was spoken with including people using the service, relatives and staff were very aware of the procedure but also feel happy to discuss any concerns with any member of staff or the deputy and manager. The number of complaints received since the last visit is eleven, complaints are responded to more effectively than previously and the manager is aware of how to investigate safeguarding adults issues and formal and informal complaints. Surveys confirmed that people know how to complain and the atmosphere is more open and staff are approachable. Staff have received abuse training and those spoken with are aware of the different types of abuse and how to whistle blow. This is underpinned with a robust procedure which staff familiarise themselves with. This area has improved greatly during the past 12 months, with staff having a more positive attitude and manner towards people living in the home, relatives and other staff. South Park DS0000027981.V333756.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. People who use the service experience good quality outcomes in this area. People live in an extremely clean and pleasant environment where infection control procedures are adhered to. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home has undergone a huge refurbishment during the past six months. The home now offers hotel style accommodation with communal areas being varied and plentiful for people to enjoy. The entire home has a pleasant, clean and welcoming feel which has had a positive impact on people using the service. All areas examined were fresh smelling with décor maintained to a high standard. A few areas need to be completed which include redecoration of some of the bedrooms. Three people spoken with on the general unit commented on how impressed they were with their new rooms. One lady said South Park DS0000027981.V333756.R01.S.doc Version 5.2 Page 16 ‘its like living in a 5 star hotel’. One person visiting the service confirmed that she would be arriving next week, part of this decision was due to the newly refurbished areas. Staff have had infection control training which was evident in the training records and observations of the laundry and protective clothing being worn confirmed this. The sluice areas were clean and secure and staff had an understanding of the different skips/bags used for different types of laundry. People were observed wearing clean and well ironed clothes. South Park DS0000027981.V333756.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People who use the service experience good quality outcomes in this area. People are cared for by sufficient staff who are safely recruited, competent and appropriately trained to meet individual needs. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People are cared for by staff in sufficient numbers, this was confirmed through observation on both units and when inspecting the duty rota. Staff surveys were completed and whilst there are occasions when the home is short staffed this is usually due to sickness. People spoken with all confirmed that staff are easily accessible and available when needed. Staff were competent in their care practices and had a good understanding of how to meet individual needs. Induction training takes place and three staff files were checked to confirm this. Staff were spoken with who detailed the elements of the induction programme (equivalent to Skills for Care). The manager is very aware of how to recruit people safely, two written references are obtained and police and vulnerable adults checks are made prior to commencement of employment. For those who are registered nurses their personal identification number is checked through the nursing and midwifery council, records confirmed this to be the case. South Park DS0000027981.V333756.R01.S.doc Version 5.2 Page 18 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. People who use the service experience good quality outcomes in this area. The home is clearly run in the best interests of the people using the service. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The manager of the home has been instrumental in improving the service, she is registered with the CSCI and has completed her managers award. She is open, approachable and competent is implementing effective systems to move the service forward. Everyone spoken to including people using the service, relatives and staff all confirmed the positive impact on the home since the manager started 12 months ago. South Park DS0000027981.V333756.R01.S.doc Version 5.2 Page 19 Four Seasons have developed a robust quality assurance system which includes seeking views and opinions of people and their relatives. An audit system is in place which includes care plans, medication, accidents and health and safety. The manager continuously monitors aspects of the home to identify what improvements have taken place and this is clearly documented. People confirmed they can raise issues at the three monthly relatives meetings or on an informal basis when the manager and deputy are on each unit. The home has records regarding individual monies, three were checked and found to be maintained effectively. Computer printout of personal allowances are available and invoices are sent to people regarding hairdressing, chiropody or toiletries. No concerns were raised in this area. The health and safety system was discussed, more in-depth monitoring of this system is now taking place. A fire risk assessment has been completed and records pertaining to fire alarm testing and fire drills was evident. Water temperatures are recorded monthly and these were found to be normal. Certificates regarding yearly checks of hoists and lifts were evident in the annual quality assurance assessment, and information regarding electrical wiring and gas safety was also available. People said they felt safe in their environment and clear systems were in place to protect people from harm. Staff have undergone mandatory training for fire safety, moving and handling, infection control and first aid. Health and safety is discussed and evidence of this was available. South Park DS0000027981.V333756.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 South Park DS0000027981.V333756.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP9 Regulation 13 Requirement Medication must be destroyed on a regular basis. A stock balance on the dementia unit must take place to ensure a clear audit trail is evident. Timescale for action 03/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations South Park DS0000027981.V333756.R01.S.doc Version 5.2 Page 22 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.V333756.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!