Inspection on 21/10/05 for South Park Residential Home

This inspection was carried out on 21st October 2005.

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

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

Other inspections for this house

South Park Residential Home 03/07/08

South Park Residential Home 02/05/07

South Park Residential Home 04/05/06

South Park Residential Home 25/04/05

South Park Residential Home 05/10/04

South Park Residential Home 22/04/04

South Park Residential Home 08/01/04

South Park Residential Home 15/10/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE South Park Residential Home 193 South Park Road Wimbledon London SW19 8RY Lead Inspector Jon Fry Unannounced Inspection 11:30 21 October 2005 st 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 Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service South Park Residential Home Address 193 South Park Road Wimbledon London SW19 8RY 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) 0208 296 9602 020 8944 1915 lanoireuk@aol.com South Park Residential Home Ltd Ms Rose Hughes Care Home 11 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (11) of places South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25/04/05 Brief Description of the Service: South Park Residential Home provides accommodation and care for eleven older people. The home is privately owned and is located in a residential area of Wimbledon, close to shops, churches of different denominations and good public transport links. Accommodation is provided over two floors serviced by a lift. The home is staffed twenty four hours a day with additional catering and domestic staff provided. South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by a regulation inspector on the 21 October 2005. The inspection took place over four hours. The inspector spoke individually with five residents, one visitor, the manager and two members of staff. A number of records were examined, as well as a tour of the communal areas of the home. What the service does well: What has improved since the last inspection? What they could do better: Only three out of the nineteen Requirements made at the previous April 2005 inspection have been fully actioned by the Registered Persons. The registered provider supplied a written action plan to the CSCI stating how the nineteen Requirements made at the previous April 2005 inspection were going to be addressed. Only three out of these nineteen Requirements have been fully actioned. South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 6 The CSCI will consider taking Enforcement Action against the registered persons should these issues not be satisfactorily addressed at the next inspection visit. 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 Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 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 Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Resident’s benefit from their needs being appropriately assessed before admission. Information provided to residents about the home needs updating. EVIDENCE: There is an appropriate procedure to make sure that the individual needs of a resident are assessed before they move into the home. These assessments were seen for two clients whose care files were examined. The residents Guide (Service Users Guide) needs updating to give better information to individuals on admission to the home. This document must reference the CSCI and also say where a copy of the last inspection report can be seen. The Statement of Purpose for the home has been reviewed since the last inspection took place in April 2005. South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 and 11. Care plans require further review and re-organisation in order for these to be useful working documents for care staff. The healthcare needs of residents are satisfactorily met. Residents feel that they are treated with respect by staff working at the home. EVIDENCE: Feedback from individual residents was very positive regarding the care provided at the home. Comments included “I’m well looked after, “more of a hotel for me” and “there is a high level of concern for my well-being”. All five residents spoken to said that they were treated politely and with respect by staff. Care plans were observed to be in place for two residents whose documentation was looked at and these were being reviewed on a monthly basis. A number of different formats are in use for care planning and this makes it difficult to obtain good information quickly. The manager said that she was working on a new care plan document and this was discussed at the time of inspection. South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 10 The Requirement from the previous April 2005 inspection has been carried forward. It is important that each care plan fully addresses individual needs and clearly say how these are to be met. The healthcare needs of resident are met. All residents are registered with a local GP practice and arrangements are made for regular dental, optical and chiropody care. Staff consult with appropriate health care specialists as required and residents are supported to attend health care appointments. Information concerning individual wishes following death are still not consistently recorded within the care plans. The home must ensure that this information is obtained and recorded. If a resident declines to discuss these details, this should be documented as such. South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15. The dietary needs of residents are well catered for with a balanced and varied menu available. Residents gave positive comments on the quality and quantity of food on offer. EVIDENCE: Residents gave positive comments on the food provided. One resident said that the food was “good” and another said “quite good”. One resident stated that the manager regularly asked residents about the available menus and if individuals wanted any changes made. To ensure all residents receive a varied nutritional diet a record of food is maintained. Fish and chips were served for lunch on the day of inspection. Alternatives stated as available at each mealtime include salads, omelettes and sandwiches. Resident’s bedrooms seen were personalised to each individual. Residents are able to bring personal possessions when they move in and this is only restricted by the room space available. South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. A satisfactory complaints procedure is in place that is supplied to residents on admission to the home. EVIDENCE: Residents spoken to during this visit expressed confidence in the manager to deal with any concern or complaint they might have. None of the residents spoken to had any concerns at the time of the inspection visit. The home keeps a record of any complaint along with actions taken and outcomes. Two complaints had been recorded from residents since the last inspection of the home. Both had been satisfactorily addressed by the manager. The home still needs to ensure that a full up to date version of the Local Authority Protection of Vulnerable Adults (POVA) procedure is obtained for reference purposes. Training is also still required for all care staff working at the service and the Requirement made at the previous inspection has been re-stated. South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24 and 26. The home provides comfortable and homely accommodation to residents. Further replacement of communal carpeting must take place to enhance the appearance of the home. The bathroom facilities meet the needs of residents currently accommodated. Resident bedrooms are well maintained and personalised to individual taste. The premises are maintained to a good standard of cleanliness and kept free from offensive odour. EVIDENCE: The communal areas of the home are homely in appearance – the lounge and dining room area provides a pleasant area for residents to use. South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 14 Individual bedrooms provide comfortable homely accommodation for residents. All were observed to be kept very clean and free from offensive odour. The bedrooms seen were personalised to resident’s own tastes and interests. Comments from residents included “I have a lovely room” and “its bright and cheerful”. Requirements have been re-stated within this report about the following issues: communal stairwell / hallways – carpets need replacing lounge / dining room – carpet needs replacing laundry area – suitable shading is required first floor hallway – an electrical socket needs replacing Following the previous report of April 2005, the provider supplied an action plan to the CSCI stating how the issues listed above were going to be addressed. It is noted that none of the stated improvements have been made despite these written assurances. South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The home has sufficient staff on duty to meet the needs of the residents. The recruitment procedures need improvement to fully protect the welfare of residents. Opportunities are available for staff to attend training courses. Future training plans should include abuse awareness and dementia training. EVIDENCE: Residents gave very positive comments on the staff. Staff were described as “all very nice”, “nice” and “very very good”. All residents spoken to said that there were enough staff around. All new staff must be checked against the POVA list prior to commencing employment at the home. There were no records available to confirm that these checks had taken place for three new members of staff. Other recruitment records examined included application forms and identity documents. Two written references were not available for these staff members at the time of this inspection. In order to ensure that all staff receive appropriate training an individual training and development plan must be kept in the home for each member of staff. This must show at least three days paid training annually is provided for each staff member. The Requirement from the last inspection for all staff to attend abuse awareness and dementia training has been carried forward into South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 16 this report. The manager of the home was trying to arrange this training at the time of inspection. One member of staff spoken to reported that they had completed their NVQ Level Two award and had attended Food Hygiene and Manual Handling training. The training materials for new care staff still require review to ensure that these are consistent with the national Skills for Care common induction standards. South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38. The systems for consultation with service users and their representatives require further development. Records of residents money are accurately maintained with suitable secure storage provided. Health and Safety practices require improvement to fully ensure clients health and welfare. EVIDENCE: The home aims to hold monthly resident meetings and minutes from June 2005 were seen to include discussion about food, activities and equipment. A quality assurance system has still not been fully developed that includes annual questionnaires for residents, their relatives / representatives and other stakeholders. The information obtained can then used to inform an annual South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 18 development plan for the service. Monthly unannounced visits by the registered provider are taking place. These reports are still not being regularly supplied to the CSCI. The records for personal monies for four residents were checked. These were were satisfactorily maintained and the security arrangements for cash amounts held had been improved since the last inspection took place. A Requirement has been made to make sure that records are available for any individual bank accounts opened for residents by the service. Hot water temperature checks must be carried out on a weekly basis for all bath and shower outlets with full records kept. Documentation must also be made available to confirm that the five yearly test of the fixed electrical installation at the home has been carried out. The manager must make sure that the CSCI is notified of any incidents and accidents as required by law. South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 19 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 3 X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 2 X X 2 South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 5 (1) Requirement The Registered Persons must ensure that the Service Users Guide references the CSCI and specifies where a copy of the last inspection report can be accessed. (Previous timescale of 01.06.05 not fully met) The Registered Persons must ensure that care plans fully address residents’ individual needs. Care plans must be fully reviewed and re-organised in order to be utilised as an effective working tool for staff. Consistent formats must be put in place for care planning. Assessments must be consistently applied and individual documentation signed & dated by staff. (Previous timescale of 01.07.05 not fully met) 3 OP11 15 (1) The Registered Persons must DS0000027229.V258108.R01.S.doc Timescale for action 01/12/05 2 OP7 12 (1) 15 (1) 01/02/06 01/02/06 Page 21 South Park Residential Home Version 5.0 ensure that individual residents wishes are obtained and recorded regarding arrangements following death. (Previous timescale of 01.06.05 not fully met) The Registered Persons must ensure that an up to date Local Authority procedure is available at the home with regard to the Protection of Vulnerable Adults (POVA). (Previous timescale of 01.06.05 not fully met) The Registered Persons must ensure that all care staff receive abuse awareness (POVA) training. Full records of this provision must be maintained at the home. (Previous timescale of 01.07.05 not fully met) The Registered Persons must ensure that the carpet in the ground floor hallway, stairwell and first floor hallway is replaced. (Previous timescale of 01.06.05 not fully met) The Registered Persons must ensure that suitable shading is provided in the laundry area of the home. (Previous timescale of 01.07.05 not fully met) The Registered Persons must ensure that the electrical socket in the first floor hallway is replaced. (Previous timescale of 01.06.05 not fully met) The Registered Persons must DS0000027229.V258108.R01.S.doc 4 OP18 13 (6) 01/12/05 5 OP18 13 (6) 01/02/06 6 OP19 23 (2) (b) (c) (d) 01/02/06 7 OP19 23 (2) (b) (c) (d) 01/02/06 8 OP19 23 (2) (b) (c) (d) 01/11/05 9 OP19 23 (2) (b) 01/02/06 Page 22 South Park Residential Home Version 5.0 (c) (d) ensure that the carpet in the communal lounge and dining area is replaced. The Registered Persons must ensure that a POVA check is completed for all new care staff prior to the commencement of their employment. (Previous timescale of 01.05.05 not fully met) The Registered Persons must ensure that recruitment information for all individual staff members is obtained as required by Schedules Two and Four – The Care homes Regulations 2001. The Registered Persons must ensure that all care staff receive Health and Safety, First Aid, Food Hygiene and dementia training. Full records of training must be maintained at the home. This includes content of any in-house training facilitated. Three days paid training annually must be evidenced for each staff member (pro-rata for part-time staff). (Previous timescale of 01.07.05 not fully met) 01/11/05 10 OP29 7, 9, 19 11 OP29 7, 9, 17, 19 01/12/05 12 OP30 18 (1) 01/02/06 13 OP30 18 (1) The Registered Persons must ensure that staff induction training is to national standards (Skills for Care). (Previous timescale of 01.07.05 not fully met) The Registered Persons must ensure that a quality assurance system is put in place for the DS0000027229.V258108.R01.S.doc 01/01/06 14 OP33 24 (1) (2) 01/02/06 South Park Residential Home Version 5.0 Page 23 home. This must include annual questionairres supplied to residents, relatives / representatives and other stakeholders. Views obtained must inform the annual development plan in place and should be included within the Service Users Guide. (Previous timescale of 01.07.05 not fully met) The Registered Persons must ensure that a copy of the monthly unannounced visit is supplied to the CSCI on an ongoing basis. 15 OP33 26 (4) 01/11/05 16 OP35 16 (2) 17 (2) 17 OP38 13 (4) (Previous timescale of 01.05.05 not fully met) The Registered Persons must 01/12/05 ensure that accurate records are available for bank accounts opened by the home on behalf of service users. 01/01/06 The Registered persons must ensure that a five yearly electrical installation test is carried out by a suitably qualified person. A record of this test must be supplied to the CSCI within the timescale specified. (Previous timescale of 01.06.05 not fully met) The Registered Persons must ensure that weekly records of hot water checks include specific recorded temperatures for bath / shower outlets. (Previous timescale of 01.06.05 not fully met) The Registered Persons must DS0000027229.V258108.R01.S.doc 18 OP38 13 (4) 01/11/05 19 OP38 37 (1) (2) 01/11/05 Page 24 South Park Residential Home Version 5.0 ensure that written notifications are made to the CSCI as required by Regulation 37 – The Care Homes Regulations 2001. 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 Refer to Standard OP31 Good Practice Recommendations It is strongly recommended that the manager be supplied with a computer and printer for the office. This will enable records / documentation to be updated onsite. (Recommendation not actioned from previous inspection report) South Park Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Residential Home DS0000027229.V258108.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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