Inspection on 20/07/05 for Western Park View

This inspection was carried out on 20th July 2005.

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

Western Park View 26/07/07

Western Park View 25/07/06

Western Park View 20/12/05

Western Park View 02/12/04

Western Park View 15/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Western Park View 390 Hinckley Road Leicester Leicestershire LE3 0WA Lead Inspector Gillian Adkin Unannounced 20 July 2005 09:30 th 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 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. Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Western Park View Address 390 Hinckley Road Leicester Leicestershire LE3 0WA 0116 2470032 0116 2470032 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Western Park (Leicester) Ltd. Mrs Rosalind J McArdle Care Home with Nursing 60 Category(ies) of OP Old Age (60) registration, with number PD Physical Disability - over 65 (60) of places PD(E) Physical Disability - over 65 (60) Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No person under 55 years of age who falls within category PD may be admitted to the home. Date of last inspection 02.12.05 Brief Description of the Service: Western park view Nursing and Residential home is owned by a limited company Western Park (Leicester) limited. The home provides accommodation for sixty service users who fall within the categories of Old Age, and Physical Disability over sixty years of age. The home is purpose built and is set in secluded grounds in a residential area close to Western Park and Leicester City Centre. The home has fifty-four single bedrooms and two double all of which are en-suite situated on two floors which are accessed by two passenger lifts There are four lounges and a large conservatory. There are attractive garden areas to sit outside and ample parking is available. The home is managed by a qualified nurse manager and employs both trained and care staff. The home is a non-smoking home, however provision is made for residents who smoke in a separate area. Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected against the Regulations as in the Care Standards Act 2000. This was an unannounced inspection, which took place over one day and commenced at 9.40 am on 20/07/05.The inspection took 6 hours. The operations manager facilitated the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting four residents and tracking the care they received through review of their records, discussion with them, and their relatives, care staff and observation of care practices. This inspection report additionally addresses specific areas where requirements and/or recommendations were identified at the previous inspection. During this inspection a tour of residents individual accommodation took place and the inspector viewed internal records, and four care plans. The inspector spoke to residents, nurses, care and ancillary staff, and relatives. Discussions with the operations manager regarding requirements made at the last inspection indicated that all of the requirements made had been met. Three of the five recommendations made had been implemented. Comments were received from nine residents including those selected for case tracking. Additional comments made by residents about the service were very positive What the service does well: Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 6 A homely environment is provided which is appropriate to the categories of person accommodated. Staff are provided with training, which is relevant to residents needs. Residents are fully supported in maintaining spiritual needs and regular church services are held in the home. The registered manager ensures that staff and residents have opportunities to express their views at regular meetings. The registered provider obtains the views of residents during discussion with them at his regular visits to the home. The staff in the home encourage residents to be autonomous whilst offering support as required. Trained staff are provided with individual bottles of alcohol rub which they use between hand washing to ensure infection control is managed effectively. What has improved since the last inspection? The registered manager and deputy manager have made significant improvements to care plans and internal documentation. Evaluations of care plans reflect outcomes for residents. A new residential manager has been appointed to manage the care needs of residential residents. Staff spoke highly of her knowledge and support to them. A new activities organiser has been appointed and although on sick leave during this inspection, residents and staff commented on her ability to manage the social needs and requirements of individuals. The registered manager has commenced a process of monthly review meetings with residents and their families where considered beneficial and prior to annual reviews taking place in order to ensure that any problems or concerns are affectively dealt with and include all interested parties Communication in the home is much improved this was confirmed by staff spoken with. More choice has been given to residents at meal times and residents stated that food was very good now. Resident’s views are obtained on the service and how it is run. Staff and residents meetings are being held more frequently. Meal arrangements have altered to include a named carer at breakfast to assist with feeding of residents and more dependant residents are fed in the main dining room to ensure that they are monitored by the trained staff. Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Residents and their relatives are confidant in the homes ability to meet needs in relation to individual persional care. EVIDENCE: Four residents were case tracked and two of the care plans contained an initial assessment identifying care needs. The remaining two residents had been admitted prior to the current managers appointment. Of the two care plans, which contained assessments it was apparent, that care plans had been developed appropriately and addressed all associated needs and risks. Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7.9 Comprehensive care plans, which include resident’s input and safe management of medication, are in place. This ensures that care provided is appropriate, delivered by competent staff and therefore meets individual needs. EVIDENCE: All of the four residents tracked had a care plan in place, which was developed by trained or suitably competent persons. Care plans tracked identified specialist needs and reflected outcomes. Evidence was found to demonstrate that risks were appropriately addressed and specialist care provided was fully documented. Some evidence was found to support that residents had been consulted with regarding their care plan. Residents were unable to confirm the extent of their involvement. Care plans had significantly improved since the last inspection. Medication was inspected in relation to those residents tracked. Controlled drugs were also inspected. The systems of ordering, storage and administration were appropriate and safe. Trained nurses administer medication to nursing residents and trained senior care staff administer drugs to residential residents. Staff were questioned regarding policy and procedure and were aware of how to report errors. Care staff responsible for drug Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 11 administration have completed distance learning programmes to ensure competence. None of the resident’s case tracked were responsible for their own drug administration however staff responsible stated that they were aware of the need to ensure that residents were safe and of the need for risk assessments. Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12.15 The provision of good quality meals and flexible routines where individual choices and needs have been considered has resulted in resident’s specific requirements being met and overall satisfaction with the service provided. EVIDENCE: Residents case tracked (where practicable) and others spoken with stated that routines in the home are usually fairly rigid although choices were offered regarding bed times etc. Two residents spoken with stated that they were very happy with the current routines, which met their individual preferences. One residents did state that he would like to go out more often as he had been a “countryman and like the fresh air” A residents stated that they regularly attended the church services which are held each month. Activities are provided by an activities organiser each day dependant on activities planned they are either am or pm. During this inspection the activities organiser was off sick and no arrangements were in place to ensure that residents were suitably occupied other than the TV being on in the conservatory and lounge. A number of residents said they were happy with the activities provided and had enjoyed the garden fete but were bored when the activities person was not there. Residents and staff stated that the activities person spends time with those unable to join in group sessions. Records were not inspected on this occasion. Social diaries were seen in two care plans tracked but both were in need of updating. Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 13 Meal and food quality featured negatively at the last inspection. During this inspection menus were inspected and were found to be much improved. The inspector observed the midday meal being served and noted that at least three choices were available and three desserts. Residents spoken with all stated that food had improved tremendously and that food was of good quality and quantity. Specialist diets were accommodated at the time of this inspection and evidence was given of current diets. Resident’s views are obtained each day by the cook regarding the midday meal records inspected indicated that residents were very happy with meals provided. Adequate staff were on duty to assist those residents who required help with their food. Drinks were noted to be served regularly and one resident said the staff regularly “fill up my flask with coffee” Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16.18 Complaints are managed adequately and responded to within given time scales. An adult protection procedure is in place to ensure staff are confident in responding to suspicion or allegation of abuse this ensures the protection of residents in the home. EVIDENCE: There is a clear complaints procedure on display in the home which service users and relatives spoken with appeared to be aware of. Complaints procedures are included in internal documentation including the service user guide. Notices are also placed in prominent places around the home to inform visitors of the registered provider’s contact details in the case of concerns or complaints. Most service users’ stated that they would refer their complaint in the first instance to the manager or deputy other stated that their relatives would make any concerns known to the management on their behalf. Complaint Records were inspected and demonstrated that recent complaints are being dealt with satisfactorily using the internal system. One complaint was noted to have no recorded outcome and the registered provider has been asked to confirm the outcome of this with the Commission. Residents tracked and other spoken with all stated they had no complaints about the home. Staff spoken with at this inspection showed good awareness of Protection of Vulnerable Adults procedure and whistle blowing policy. Four Staff personnel files were inspected demonstrated that CRB disclosures were in place and that Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 15 two had received adult abuse training. One resident stated “he felt safe in the home” Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 16 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 standard(s) 19.25 The home is clean, comfortable and premises are well maintained resulting in a comfortable living environment for residents. EVIDENCE: An inspection of the premises including individual rooms (residents tracked) and communal areas confirmed that all areas were clean and well maintained and free from odours. The home is routinely maintained and the registered provider employs a full time maintenance person who has responsibility for day-to-day maintenance, decoration and repairs. Grounds were noted to be safe and accessible. Maintenance records were inspected and all records inspected were up to date. Service Contracts are in place for equipment including hoist and lifts. Water temperatures are tested weekly and all temperatures recorded were within normal range. The home is well lit, heated and adequately maintained however a number of residents stated that the conservatory was very hot and there were no blinds at the windows to provide shade. This was discussed with the operations manager who agreed to take action to improve ventilation in this area. Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 17 Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27.29 The needs of residents are safely met a thorough recruitment and selection process and adequate numbers of suitably skilled and trained staff. EVIDENCE: Staffing levels were discussed with residents and staff and it was apparent through discussion that numbers of staff and staff deployment had improved since the last inspection. Only one person raised concerns over staff’s ability to meet needs and stated that staff response times to residents requests to use the bathroom was often delayed longer than five minutes. Staff stated that where the manager was unable to cover shifts with internal staff they were covered by agency staff. It was further suggested that where practicable a member of staff used as a floater would be beneficial particularly on the early shift. A calculation of staff hours demonstrated that the home was meeting the minimum staffing levels as agreed with the previous registration authority. The manager is supernumerary and the residential care manager has three or four days per week to complete management tasks. Inspection of rosters indicated that some staff were working an excessive number of shifts to cover annual leave or sickness this could result in staff becoming over tired and unable to work efficiently. The registered provider is recommended to monitor shift allocation during periods of annual leave. Dependency levels in the home are monitored by the registered manager or the trained staff this is reflected in staffing levels. Four Staff files were inspected and all files inspected contained essential information including work permits, written references and CRB disclosures. It Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 19 was noted however that none of the files contained any evidence of identification or photographic identity. The operations manager stated that they had been informed these documents were not required to be contained in these files. Schedule 2 Of the Care homes Regulations details all documentation required to be included in staff files. Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33.38 The home is run in the best interests of residents and their welfare is promoted. EVIDENCE: Discussions with residents and records inspected demonstrated that their views are considered. The registered provider discusses the running of the home with residents during his monthly visits to the home. A resident stated that the activities organiser had just completed a satisfaction survey with them approximately two weeks ago. Regular meetings are held for residents/relatives and staff. Staff spoken with stated they were free to voice their opinions at the meetings and considered they were taken seriously. Health and safety records were inspected on this occasion and included * COSHH Data sheets * Manual handling training records. Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 21 *Accident records/Incident records. *Fire records. *Risk assessments. All records inspected were well maintained and up to date including service contracts for machinery. A residents who was case tracked had recently been involved in an accident in the home where machinery was in use. Records inspected indicated that the machinery was recently serviced and approved by the engineer. A notification had been made to inform the Commission for Social Care Inspection of the incident and appropriate action taken following the incident. The resident sustained no injuries as a result of the incident. Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 3 x STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 3 Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 23 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 29 Regulation Reg 7.9.19 Sch2 Requirement All Staff files must contain proof of identity and photographic evidence of identity Timescale for action 31.08.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 3 7 9 12 Good Practice Recommendations It is recommended that a social history is completed during assessment of a residents and kept in their care plan. It is recommended that individual risk assessments are updated at least six monthly or more often as required accordingly to outcomes. It is recommended that residential and nursing staff receive internal medication competency training at least annually. It is recommended that appropriate arrangements are made to provide activities for residents when the activities organiser is on leave.It is further recommended that an orientation board is provided to ensure residents remain fully orientated to date and day. It is recommended that outcomes of complaints are documented and contained in the complaints register. It is recommended that ventilation and temperatures in the consvatory are monitored and appropriate action v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 24 5. 6. 16 25 Western Park View 7. 8. 38 27 takne to ensure the environment is ambient and comfortable. It is recommended that generic risk assessments are completed in full and are evaluated at least quarterly or more often as required dependant on individual risk. It is recommended that staff do not work excessive numbers of shifts which may result in them being overtired and unable to work efficiently. Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection The Pavilions 5 Smith Way, Grove Park Enderby, Leicestershire LE19 1SX 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 Western Park View v233584 c51 c01 s1932 western park view v233584 200705 - stage 4.doc Version 1.30 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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