Inspection on 09/07/08 for Canwick Court Care Home

This inspection was carried out on 9th July 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Canwick Court Care Home 27/02/09

Canwick Court Care Home 14/11/06

Canwick Court Care Home 10/05/06

Canwick Court Care Home 24/10/05

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE South Park Care Home 78 South Park Lincoln Lincs LN5 8ES Lead Inspector Doug Tunmore Unannounced Inspection 9th July 2008 09:15 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 Care Home DS0000064152.V368003.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 Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Park Care Home Address 78 South Park Lincoln Lincs LN5 8ES 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) 01522 544595 01522 544230 southpark10@btconnect.com www.guardiancarehomes.co.uk Guardian Care Homes (UK) Limited Manager post vacant Care Home 31 Category(ies) of Dementia - over 65 years of age (31) registration, with number of places South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care with nursing for service users of both sexes whose primary needs fall within the following categories:Dementia - over 65 years of age (DE)(E) - 24 (Nursing) Dementia - over 65 years of age (DE)(E) - 7 (Personal Care) The maximum number of service users to be accommodated is 31. 2. Date of last inspection 14th November 2006 Brief Description of the Service: South Park Care Home is registered to provide nursing care and personal care for 31 people over the age of 65 with dementia and up to 4 people with dementia under 65 years of age. The home has an acting manager in place who is not registered. The home is situated to the south of Lincoln city and is served by a bus route and is within walking distance of the town centre. The property is a large detached Victorian building laid out over 4 floors. The top floor is for staff and an administration area. The first floor comprises of resident bedrooms and the ground floor has bedrooms and communal areas. The lower ground floor has the main kitchen and the residential care unit, which can accommodate 9 residents. This unit is called Heathlands and has its own entrance. The fees at the inspection visit on the 08/07/2008 ranged from £348:00 to £720:00 each week. Extras are for hairdressing, chiropody, personal newspapers and magazines. The provider makes no charge for escorting residents to hospital. Information about the home can be obtained from the manager of the home. The service user’s guide is available from the manager and is kept in the office. The service users guide has also been placed in all residents’ bedrooms. South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means that people who use this service experience adequate quality outcomes. One inspector who was accompanied by an expert by experience undertook this visit to the home. This formed part of an unannounced key inspection. This visit took into account any previous information held by The Commission for Social Care Inspection (commission) including the homes previous inspection reports and the homes Annual Quality Assurance Assessment form, hereafter in this report referred to as AQAA. ‘Have Your Say’ surveys were sent to the home by the commission and residents returned ten, which were completed with help from relatives. The site inspection consisted of case tracking a sample of two residents records and assessing their care. The expert by experience spoke with four residents, two visitors and one carer. The inspector spent time with the deputy manager, the care centre manager (administrator), the cook, two carers and three relatives. Observations were made throughout this inspection of the relationships between people who live in the home and carers. A partial tour of the home and a review of a sample of the records were also included. What the service does well: What has improved since the last inspection? The deputy manager confirmed that a number of requirements and recommendations made at the last inspection have been addressed. She also commented that training programmes are ongoing for all members of staff South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 6 working at this establishment. All residents’ files are being updated with a view to looking at outcomes for residents and not being task centred. Decoration of the home is ongoing, with plans for an extension that would be built in the near future. 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 Care Home DS0000064152.V368003.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 Care Home DS0000064152.V368003.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): Standards 1, 2, 3,4 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive information about the home, which helps them to make an informed decision about where to live. The clear assessment process assures them that their needs can be met within the home. EVIDENCE: The providers AQAA tells us that; ‘we provide individualised care in a homely environment and respect and value each individual resident’. Eight of the ten surveys received from people who live at the home confirmed that they received information about this home prior to admission enabling them to decide if it was the right place for them. Specific comments were ‘I South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 9 was shown the room to be allocated to my wife and from my observation she is receiving the care and support she needs’ ‘Another comment was ‘my mother was visited in her previous home by the South Park senior nurse for her assessment. I visited South Park and was shown around and discussed my mothers needs with the senior nurse and met members of staff’. A review of all information available prior to this inspection and evidence seen at this inspection in residents files and care plans showed that the home does not admit residents without a care assessment being undertaken. Prospective residents are also written to by the provider confirming whether they can meet the residents care needs or not. There was also evidence of hospital needs assessment were kept in resident’s files. One of the two visitors stated that their relative had been an emergency admission and staff had been thoughtful and kind during the admission process. We looked at two files of people who were being case tracked and it was found that they did not contain contracts. The care centre manager confirmed that this would be undertaken when the local authority contract was received. There are no intermediate care services provided at the home. South Park Care Home DS0000064152.V368003.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): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People benefit from comprehensive care plans, which accurately reflect their assessed needs. Residents personal and health care needs are met so as to ensure their wellbeing. The dignity of people is not promoted by having their own clothing. An accurate record is not made of medication given to people so as to ensure their safety. EVIDENCE: The providers AQAA states that;‘ Residents needs are reflected in their care plans which are evaluated monthly or as often as required. Residents are admitted only after a full assessment of their needs is carried out to ensure these can be provided. Care staff read care plans regularly’. South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 11 Seven of the ten surveys received confirmed that residents felt that they receive the care and support, including the medical support they need. The remaining felt that they usually got the support they need. A written comment was ‘the staff always keep me up to date with my mothers condition, either personally or by telephone’. The Quality Assurance Officer from Lincolnshire County Council who is monitoring this home visited on the 08/05/08 and found that ‘Although the care plans used by the company are generic, staff add supplementary information in the variance field (part of the care plan) which is very informative, furthermore the monthly evaluations are thorough and provide further instruction to staff. The care file examined contained up to date care plans, permissions, risk assessments and a body map’. Three visitors were seen by the inspector and one commented that; ‘staff nurses are brilliant, they look after my wife very well and she is always clean. However, she has somebody else’s skirt on at the moment - this happens sometimes’. The minutes of the care meeting dated 17/06/08 evidences that ‘clothes are getting mixed up in drawers’ and laundry is a problem and this will be sorted’. The residents that the expert by experience spoke to were not able to tell her if they were involved in developing & reviewing care plans. However, the visitors which I spoke to offered reassurances that if they felt their relatives were in need of anything needing adding to their care plan the ‘lady in blue’, the care worker always saw to it. The minutes of the relatives meeting held on the 06/05/08 also confirmed that relatives are concerned about clothes shrinking and the loss clothes. We looked at two files of residents who were being case tracked. It was found that care plans had recorded the approach to be taken in relation to maintaining their privacy and dignity. We looked at resident’s medication sheets and it was found that an inaccurate record was kept. One resident from each unit had not had medication signed as given for that morning. The deputy manager stated that she would check to ensure medication was given and sign medication sheets as appropriate. No residents self medicate in this home. A visit from the pharmacist was undertaken on the 26/02/08 and no issues were raised about the storage and administration of medication. At the time of this visit one GP visited the home and also a psychiatrist to see residents. The deputy manager was observed throughout this inspection talking to bereaved relatives and a visitor wanting information about his wife’s South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 12 medical condition. On both occasions the deputy manager was seen to be very professional, compassionate and supportive in difficult circumstances. South Park Care Home DS0000064152.V368003.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): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Mealtimes are not managed for the benefit of people living in the home. Activities are not always available to those people who require stimulation. EVIDENCE: The providers AQAA tells us that ‘we encourage residents to continue to use the skills they possess. Encourage friends and relatives to visit to enable family activities to continue’. Surveys show that the majority of people felt that activities are either usually available or sometimes available. Specific comments made in resident’s surveys were; such activities seem to take place at times other that when I visit’. Another comment was ‘would like more activities’. South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 14 The home has an activities organiser who works 30 hours a week. We looked at the activities book and found a list of activities undertaken by the activities worker; these included making paper fans, wheelchair walks, dominoes, sitting in the garden and a trip to an RAF base. Photographs were seen of residents at the RAF base and of an entertainer at the home. There were no activities taking place on the day of this visit. The inspector saw two carers and one stated that ‘the activities worker spends more time as a carer and was asked to fill in the activities book’. The activities worker was not available at the time of this inspection. The deputy manager stated that ‘the activities organiser undertakes care duties due to staff shortages, but only occasionally’. Those relatives who the inspector spent time with confirmed that they were made welcome and were offered refreshments during their visit. One specific comment was ‘staff are welcoming and helpful at all times and spend time with me if I want to know anything which puts my mind to rest’. The expert by experience spoke to both residents and relatives about their experience of care at South Park these views were mixed. The telephone downstairs in the residential area appeared an issue. There is no telephone to make outgoing calls. One service users daughter living in the south of England would like to speak to her on occasions but unable to do so. A second service user said she had asked frequently to make calls to friends but had been ‘ignored’. This lady has only been at South Park for 2 weeks and had much to offer negatively about her care stating she has been ‘left in bed until 10am, then told if she had breakfast she wouldn’t want any lunch.’ She also stated that she felt ‘alone & not bothered about, left to it’. She also objected to a male member of staff dressing her. Surveys also showed a mixed review of meals taken at this home. A small number felt that they always liked the food and others sometimes or usually. Comments ranged from ‘the meals seem to me to be ample and of good quality’ to ‘no complaints as far as I know’ and my mother prefers sweet food and a pudding is given instead of a savoury main meal, plus supplement drinks’. We looked at files of those people who were being case tracked and found that their likes and dislikes were recorded. The inspector observed the mealtime in the nursing unit ‘South Park’. It was seen that the mealtime was poorly managed due to the lack of staff available and the number of residents needing to be fed both in the dining room and for those who were elderly and frail in their bedrooms. South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 15 The deputy manager confirmed that there were twelve people to be supported to eat their meals, seven of which are fed in their beds due to being frail and elderly. There are twenty-one residents to be supervised during lunch and four staff and the nurse on duty to carryout this task. Observations made were that not all residents are static during lunch. The deputy manager also stated that sometimes puddings are served three quarters of an hour after the main meal; ‘meal times are a nightmare’ and at tea time there is one less member of staff. She also confirmed that the handyman on occasion had helped in this task. It was noted that some visitors also attend and help support their relatives during lunch. South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures for addressing and monitoring complaints and concerns are in place to protect residents who are vulnerable. Adult protection issues are taken seriously and the manager would seek advice if she had concerns. EVIDENCE: The providers AQAA confirms that ‘all staff have POVA training as mandatory. Open door for relatives and residents to discuss any concerns. Complaints policy and procedure in place. Whistle blowing policy in place and staff are aware. All complaints are documented and are dealt with by the Manager. Regional Manager kept informed’. All surveys showed that they the relatives and residents know how to make a complaint and no concerns were raised. A number of allegations had been received by the social services safeguarding team concerning this home. A monitoring process has been put in operation and the last visit by the Quality Assurance Officer from Commercial Services confirmed that ‘improvements identified through this process were completed and that feedback to the case conference would be that any issues and concerns had been addressed and no further actions was required from Safeguarding’. South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 17 A former complainant commented that ‘it’s a lot better at the moment and staffing levels seem to have improved. One nurse always keeps me in the picture’. Residents with whom the expert by experience spoke to said that they would raise any concerns with the ‘lady in blue’ member of staff should they have the need but were unaware who else to complain to. All spoken to said they felt safe & secure. The deputy manager confirmed that the provider continues to work closely with those agencies charged with protecting residents. The providers training file was seen and showed that 50 of staff received safeguarding vulnerable adults training in May 2008 and further training is planned for 31 July 2008. The complaints file was seen and evidenced that those complaints received have been addressed. South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in clean, well-decorated, homely and safe accommodation. EVIDENCE: The providers AQAA states that, ‘safe and homely atmosphere with areas for residents to choose from. Maintenance is ongoing. Health and safety is paramount at all times. All bedrooms are decorated. Dining room has been refurbished. Lounges have been redecorated’. All surveys show that the home is kept clean and tidy and there are no unpleasant odours. A specific comment made was that a visitor ‘found his fathers bedroom dirty on one occasion, complained and this was dealt with’. South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 19 A previous inspection carried out on the 14/11/06 found the home to be clean, tidy and free from obstructions to mobility; and the décor and furnishings were well maintained. Hoists, a specialist bath and specialist mattresses are in place in accordance with care plans. Call bells are in reach of people in all areas of the home. However, the recommendation regarding the ‘use of recognition aids for people who have a dementia, for example colours, pictures or surface textures; and bedrooms and communal areas contain very few personal items such as photographs or ornaments’ has not been fully addressed. The deputy manager stated that recognition aids have been acquired and are to be fitted within the next week and the commission would be informed. A tour of bedrooms found that a number had been personalised whilst others were not due to challenging behaviours of some residents. The expert by experience found that bedrooms appeared comfortable and well maintained. Two out of the three seen were personalized and we were given to understand this was encouraged. All residents spoken to were very happy with their rooms & environment. All felt safe in own rooms at night. Three domestic cleaners are employed and no unpleasant odours were detected during this visit. The commission has been informed by the provider that a major refurbishment is due to take place, which will provide more en-suite apartments. South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are not fully protected by the provider’s recruitment procedures. Residents benefit from a knowledgeable staff team who are well trained. Staffing levels are not always met and could lead to peoples needs not being addressed. EVIDENCE: The providers AQAA evidenced that, ‘Ensure we have CRB check and 2 satisfactory references for each prospective new member of staff. Full induction programme for new staff. Mandatory training and POVA (protection of vulnerable adults) training. NVQ (national Vocational qualifications) training All interviews are fully documented. Training records are updated monthly. Training diary for booked training dates. Ten resident’s surveys evidenced that they feel that they receive the care and support that they need. One comment was, ‘sometimes there is not enough staff on duty’. A previous inspection visit recommended that staff shortages be closely monitored so that any issues can be dealt with immediately. South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 21 We looked at the rota and it evidenced that one carer left last week and another carer is on maternity leave. The rota showed that there are forty-four hours short for night duty and fifty-five hours short on day duty. The deputy manager confirmed that she is awaiting references for one prospective carer and interviews are to take place in the near future with three other prospective carers. She also confirmed that a bank worker is undertaking shifts this week and that all shifts are covered. The inspector could not find any evidence that carers have been employed from an agency supplying carers in Scunthorpe in the last two years. Further examination of the rota showed that the normal shift pattern is seven shifts per person and three staff were undertaking eight to ten shifts on an ongoing basis. One carer stated to the expert by experience that existing staff working overtime mostly did holiday & sick leave cover. We looked at two personnel files and found that robust recruitment procedures are in place. The providers training file evidenced that carers are receiving training, which enables them to carryout their care tasks. One carer confirmed that she had undertaken induction training and dementia training, fire awareness training, medication, safeguarding vulnerable adults. Planned training for 2008 is, basic food handling, moving and handling, safeguarding training, infection control and basic life support first aid. South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has not been consistent management of this home to ensure its smooth running and maintenance of standards of care. People’s needs relating to their health, safety and welfare are protected by regular checks. Accurate accounts are kept of resident’s monies. EVIDENCE: The Providers AQAA informs us that ‘Clear and concise financial accounts for all residents. Pre-admission assessments are completed. Ensure the Home is fully staffed. All residents’ requirements are catered for. Supervisions and South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 23 Appraisals are completed on a regular basis. Performance management. Provide a clean, warm and friendly atmosphere for residents’. Evidence was given at this inspection that in the last two years there have been three unregistered managers ( one undertaking this task twice) running this home, including the current acting manager. The current acting manager Ms Sheila Doll has not as yet applied for registration as a ‘Fit Person’ to manage the care home. On the 01/02/07 the commission wrote to this company reminding them that; it is an offence for a person to work at a home without being registered. On the 08/05/08 the clinical advisor confirmed that the new acting manager for this home is to be Ms Sheila Doll. The clinical governance advisor was reminded of the commission stance on registration of acting managers. A previous visit and report dated 14/11/06 showed that ‘the new manager confirmed that he will be applying for registration with the commission straight away and he is also undertaking the Registered Managers Award’. No action was taken. The expert by experience found that residents generally didn’t feel staff asked for their views and opinions one stated ‘they are all too busy’’ None appeared to know who the new manager is, another resident commented if she had a complaint she would ‘go to the top’. Relatives claimed they haven’t seen any management for a long time in fact ‘unsure who manager is’. They felt manager should have more input and liaise with residential service users and their families thus forming a relationship whereby relatives find it easier to discuss care plans and issues. The quality assurance Officer from Commercial Services found that Resident/relatives meetings are held regularly and minutes of these meetings are held on file. The manager holds separate “surgeries” to enable discussion for individual residents and their representatives. Up to date records were seen of resident’s monies and receipts for monies spent. We looked at people’s valuables forms, which showed that a record had been made of clothing brought into the home. However, there was no record of valuables that were given to relatives for safekeeping. The providers AQAA showed that; gas safety inspections have been carried out, electrical wiring checks, fire precautions checks, and portable electrical equipment checks. The manager stated that risk assessments are available relating to the home environment. Staff had been trained in Health & Safety, Fire procedures, etc. South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 24 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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 x x x x 3 x 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 x 3 x 2 3 South Park Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP31 Regulation 8 Requirement The provider must appoint a manager who must register with the Commission. This requirement was made at the previous inspection on 05/07/06. A system must be established to ensure that all people receive their medication at the time that it is prescribed for them and that an accurate record is made to confirm that it has been given. A system must be established to ensure that people who live in the home wear their own clothes, as this is a part of the life they had prior to admission to the home and is a part of maintaining their individualism and their dignity. A system must be established to ensure that people who live in the home access activities with a check made by the manager to ensure that low staffing levels do not impinged on the activities workers time with residents. A system must be established to ensure that people who live in DS0000064152.V368003.R01.S.doc Timescale for action 08/08/08 2. OP9 13(1)(2) 08/09/08 3. OP10 12(4) (a) 08/09/08 4. OP12 16 (2) (i) 08/09/08 5. OP15 12 (3) 08/09/08 South Park Care Home Version 5.2 Page 26 6. OP27 18(1)(a) 7. OP37 16(2) (l) the home have meal times which are managed in a way that residents are supported with their meals and that carers have the time to spend in undertaking what is also an important social event. A system must be established to ensure that staffing levels are maintained to meet the individually assessed needs of people living in this home. Any staff shortages must be monitored and action taken immediately. A system must be established to ensure that resident’s valuables are recorded accurately during the admission procedures. 08/09/08 08/09/08 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 Care Home DS0000064152.V368003.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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