Care Home: Park Street Home For The Elderly

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What the care home does well The individual`s level of engagement was assessed through SOFI and people at the home showed positive signs of engagement. People at the home were alert and good interaction was observed between staff and the people living in the home. The home has a policy that a member of staff must be present in the lounge to ensure people at the home are supported to interact with each other and with their surrounding. What the care home could do better: While people at the home have good outcomes, polices, procedures and systems must be updated. The home must introduce those systems that are in line with good practice, provide information that is accessible and empower people to make decisions. This will ensure that standards of care increase and people continue to have positive outcomes. The Statement of Purpose must be reviewed to enable people to make decisions about moving into the home. The age range, admission procedure, the way dementia needs are met must be incorporated to provide detailed information about the home. Accessible formats must also be considered. The care planning process must be reviewed to introduce a more person centred approach to meeting needs. People at the home must be supported to say about the way their care is to be delivered. Achievable by the inclusions of preferred routines, likes and dislikes into the care plans. Social care needs must also form part of the care planning process. Where individuals have communication needs, their care plans must describe the way decisions are made by the person. Risk assessments must be devised for activities that include an element of risk. Risk assessments that show locking the front door and the kitchen is consistent with the level of risk.Policies and procedures that show a commitment towards safeguarding people at the home must be formulated. Whistle Blowing and Safeguarding Adults procedure must be reflect the home philosophies and follow No Secrets guidance. The recruitment process must be robust to ensure that staff employed are suitable to work with vulnerable adults. POVA First and CRB must be obtained for staff before they can work at the home. Where possible written references must be obtained from the last or most recent employer. CARE HOMES FOR OLDER PEOPLE Park Street Home For The Elderly 10 Park Street Lansdown Bath Bath & N E Somerset BA1 2TE Lead Inspector Sandra Jones Unannounced Inspection 10:00 2 & 3 December 2008 nd rd 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 Park Street Home For The Elderly DS0000008159.V373728.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. Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park Street Home For The Elderly Address 10 Park Street Lansdown Bath Bath & N E Somerset BA1 2TE 01225 425011 NONE mary.togher@btinternet.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Alice Togher Mrs Alice Togher Mary Geraldine Bowen Care Home 10 Category(ies) of Dementia (10), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (10), Old age, not falling within any other category (10) Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) Dementia (Code DE) 2. Mental Disorder, excluding learning disability (Code MD(E)) The maximum number of service users who can be accommodated is 10. 5th December 2006 Date of last inspection Brief Description of the Service: Park Street is a converted three storey Georgian town located in the centre of Bath with easy access to local shops and amenities. The home provides accommodation for 10 residents with 4 single and 3 double rooms, 2 of the rooms have en-suite facilities. The one communal lounge is on the first floor with dining room on the ground floor. There is no lift available and therefore the home would not be suitable for individuals who could not manage stairs. The home is registered to provide care for older people with dementia, individuals aged between 55 and 65 with a mental disorder and individuals over 65 with a mental disorder. The philosophy of care is that Park Street aims to provide its service users with a secure, relaxed and homely environment in which their care, well-being and comfort are of prime importance and all residents are assured they will be treated with respect and dignity according to their individual needs and wishes (From the homes Statement of Purpose) Fee £405-£650 Dependant on individual needs. Park Street Home For The Elderly DS0000008159.V373728.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 2 star. This means the people who use this service experience good quality outcomes. This key inspection visit was conducted unannounced over two days December 2008 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedures. The Short Observational Framework for Inspection (SOFI) was used to capture the experiences of people that use the service. Two hours was spent observing the care being given to a group of individuals. All observations were followed up by discussions with the manager and examination of the records. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from the staff and relatives. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the AQAA (Annual Quality Assurance Assessment) and notified incidences in the home, (Regulation 37’s). This information was used to plan the inspection visit. There are ten people are currently living at the home and four were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. What the service does well: The individual’s level of engagement was assessed through SOFI and people at the home showed positive signs of engagement. People at the home were alert and good interaction was observed between staff and the people living in the home. Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 6 The home has a policy that a member of staff must be present in the lounge to ensure people at the home are supported to interact with each other and with their surrounding. What has improved since the last inspection? What they could do better: While people at the home have good outcomes, polices, procedures and systems must be updated. The home must introduce those systems that are in line with good practice, provide information that is accessible and empower people to make decisions. This will ensure that standards of care increase and people continue to have positive outcomes. The Statement of Purpose must be reviewed to enable people to make decisions about moving into the home. The age range, admission procedure, the way dementia needs are met must be incorporated to provide detailed information about the home. Accessible formats must also be considered. The care planning process must be reviewed to introduce a more person centred approach to meeting needs. People at the home must be supported to say about the way their care is to be delivered. Achievable by the inclusions of preferred routines, likes and dislikes into the care plans. Social care needs must also form part of the care planning process. Where individuals have communication needs, their care plans must describe the way decisions are made by the person. Risk assessments must be devised for activities that include an element of risk. Risk assessments that show locking the front door and the kitchen is consistent with the level of risk. Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 7 Policies and procedures that show a commitment towards safeguarding people at the home must be formulated. Whistle Blowing and Safeguarding Adults procedure must be reflect the home philosophies and follow No Secrets guidance. The recruitment process must be robust to ensure that staff employed are suitable to work with vulnerable adults. POVA First and CRB must be obtained for staff before they can work at the home. Where possible written references must be obtained from the last or most recent employer. 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. Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): (1) & (3) Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. People wishing to live at the home must be provided with information that is up to date and in a format can be understood to ensure they can make decisions about living at the home. Assessments of needs conducted ensure that the staff have the abilities and skills to meet the needs of the people wishing to live at the home. EVIDENCE: The Statement of Purpose and Service User Guide are combined and described is the philosophy of care. It states that the philosophy of the care home is to provide the people living at the home with a secure, relaxed and homely Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 10 environment in which their care, well being and comfort is the primary importance. While the Statements of Statement of Purpose contains information about the services and facilities, it requires reviewing. The age range, the way the care for people with dementia is delivered and the admission process must be further described within the Statement of Purpose. The manager must also consider the formats used to convey information in the Statement of Purpose. The Statement of Purpose and Service User guide must be available in formats that can be understood by those people for whom it’s intended. The case records of the most recently admitted individual was examined to determine the admission process followed at the home. A copy of the social workers’ needs assessment and other documentation from outside professional ensure that the home can make assessments about the homes ability to meet this individual’s needs. The manager explained that documentation will be improved in future and assessments will be more detailed. It is evident from the documentation held that the needs of this individual cannot be met at the home and the manager has acted appropriately with this assessment. The admission procedure followed to ensure that the needs of the people at the home can be met by the skills of the staff must be appended onto the Statement of Purpose. It is acknowledged that introductory visits and trial periods are offered. However, the assessment conducted by the more must be specified within the admission procedure. Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (7), (8), (9) & (10) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. Care planning process including risk assessments must be further developed to provide a person centred approach to meeting needs. This will ensure that people have a say about he way their personal care is to be delivered and are empowered to make decisions. Medication systems are safe. EVIDENCE: Care plans in place are based on assessment of the original social worker’s needs assessments which are reviewed six monthly. For people placed by the Local Authority review meetings are convened by the social worker. The manager said that the care planning process is under review to introduce a more person centred approach to meeting needs. Within care plans, preferred Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 12 routines, the way the individual dementia care is delivered and the way the individual makes the way decisions must be incorporated. A daily record is used by the staff to record observations of behaviours and health care. Records show that people have access to GP’s, other health care professionals and NHS facilities. The service provider said that the optician and the chiropodist visits the home and four people regularly visit the dentist. One person has input from the Community Psychiatrist Nurse (CPN) and the district nurse visits another person that is diabetic. There is a locked front door and locked kitchen at night policy. Risk assessments must be completed to ensure that the action taken is consistent with the level of risk. This policy must be detailed within the Statement of Purpose to ensure people making decisions about the home are fully informed about the way the home fulfils its aims and objectives. The Privacy and Dignity policy is described within the Statement of Purpose and confirms that during induction members of staff are trained in respecting the rights of the people at the home. Induction includes the importance of closing doors and pulling curtains when delivering personal care and knocking on peoples doors and waiting for an invitation to enter before going into their rooms. Short Observational Framework for Inspectors (SOFI) was undertaken during this inspection. The staff on duty were observed using a respectful or friendly approach to coax people to undertake tasks. Staff on duty were consulted about the expectations towards care planning. Staff said that the manager usually compiles the care plan, staff read and agree on the amendments and they make entries in the daily report. In terms of ensuring that medical advice is followed, staff said that during handovers information is passed on from shift to shift. Examples from staff about privacy and dignity confirmed that the rights of the people at the home are respected. Medications are administered through a monitored dosage system by the staff Records of administration show that staff sign the records following administration and use codes to record the reasons for not administering medications. ‘When required’ medications are administered and the service provider explained the protocol for these medications. The protocol must be formalised to ensure that staff are consistent in administering ‘when required’ medications. A record of medications no longer required is maintained and the signature of the pharmacists evidences receipt of the medication for disposal. Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 13 Homely remedies are not administered from stock medications. Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (12), (13), (14) & (15) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. People at the home show signs of positive engagement and good levels of interaction were observed between staff and the people at the home. People at the home are supported to maintain contact with friends and family. The people at the home have a varied diet. EVIDENCE: Individuals social care needs are not currently part of the care planning process. The manager said that the care planning process is being reviewed to encompass social care into the care plans. A record of daily activities provided is maintained, with feedback from staff on the success of the activities Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 15 recorded. The records illustrates that people at the home go on walks, staff read books and assists with board games. The staff on duty were consulted about activities conducted at the home. It was stated that there is an expectation that staff undertake activities with the people living in the home. It was further stated that staff read to the people at the home, accompany people on walks and play board games. Regarding making decisions about activities, staff said that people would if the don’t want to participate. Short Observational Framework for Inspectors (SOFI) was used to make judgements on the individual’s level of engagement. It was conducted for two hours in the lounge and dining room. It is the policy of the home to have a member of staff present in the lounge at all times and during the inspection there were three staff in the lounge. There was a quiet atmosphere in the lounge with age appropriate music in the background, staff were observed making attempting to engage individuals. For example, board games, newspapers, books and dolls were used to engage people. Conversations between people at the home and staff was conducted at eye level and signs of positive engagement were observed. SOFI continued in the dining room during the lunchtime meal and three staff were in the dining room assisting people. There was a quiet atmosphere with no background music and people were free to eat their meals in the dining room, lounge or bedrooms. Members of staff were observed using a variety of methods to coax people to eat their meals. However, it was noted that staff were not always sitting down to assist people to eat their meals. There is a four-week rolling menu and the range of fresh fruit & vegetables held supports that people at the home have a varied diet. The home serves a continental style breakfast, cooked main mean and a lighter cooked meal at teatime. The visitors’ policy is included in the Statement of Purpose and it recognises the importance of maintaining contact with family and friends. For this reason visiting at the home is open. Two visitors were at the home during the inspection and their feedback on the standards of care was sought. Relatives said that they felt welcome whenever they visited, they were kept informed about important issues and for additional privacy bedrooms could be used. The relatives also confirmed that the same standards of care were observed irrespective of the time of their visits. Park Street Home For The Elderly DS0000008159.V373728.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): (16) & (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 that show the home’s commitment towards safeguarding people from abuse must be updated to fit the home’s ethos. People at the home are safeguarded from abuse. EVIDENCE: The home’s Complaints procedure is appended onto the Statement of Purpose, with a copy on display in the home. The manager must review the format used to ensure that the people for whom its intended can understand the Complaints procedure. There were no complaints since the last inspection. The relatives present during the inspection were consulted about the way complaints are managed at the home. It was stated that complaints are taken seriously and they would be confident to approach the manager or service provider with complaints. Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 17 The policy of the home is to follow Croner’s a consultancy offering management systems, guidance, sample policies and best practice for day-today management of a care home. At present the home uses Croner’s sample Whistleblowing, Equalities and Safeguarding Adults procedures. However, these are sample policies. The manager must adapt them to fit the philosophy of care at the home. Park Street Home For The Elderly DS0000008159.V373728.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): (19) & (26) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The people at the home live in a well maintained, safe and homely environment EVIDENCE: Park Street is a converted three storey Georgian town located in the centre of Bath with easy access to local shops and amenities. Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 19 The home provides accommodation for 10 people in 4 single and 3 double rooms, 2 of the rooms have en-suite facilities. Communal space includes a lounge on the first floor that offers enough seating for the people accommodated. The dining room is on the basement floor, there is no lift available and individuals are accompanied by the staff to access all floors. There is no lift available and therefore the home would not be suitable for individuals who could not manage stairs. At the time of this inspection the home was clean and free from offensive odours. A number of individuals require assistance with maintaining continence and this is managed in an efficient way which makes sure that rooms and communal areas of the home are pleasant and there are no offensive odours Park Street Home For The Elderly DS0000008159.V373728.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): (27), (28), (29) & (30) Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. Recruitment at the home must be more robust to ensure that staff are suitable to work with vulnerable adults. The training programme in place ensures that staff have the skills to meet the changing needs of the people living in the home EVIDENCE: The personnel files of the staff working at the home were examined to determine the robustness of the recruitment process. Competed application forms that contained full employment history, the names of two referees and disclosures of criminal background are kept. While two written references were obtained, the references from the last employer were not sought. Wherever possible the manager must ensure that at least one reference is from the last employer. With one exception, POVA first and Criminal Record Bureau (CRB) checks were obtained for the staff working at the home. While it is Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 21 acknowledge that this person is working supervised, the manager must ensure the process ensures that people at the home are safe from abuse. A member of staff currently going through the home’s induction was consulted about the process. This member of staff said that they had experience of working with people with dementia, had achieved vocational and professional qualifications. The induction is mainly based on the routines of the home; the needs people living there and familiarisation of the property. Since the last inspection, the manager has updated the induction programme for new staff. Staff receive information about dementia during the induction, are informed about the need of the people living in the home and familiarisation of the building. Statutory training follows from the in-house induction and leads into vocational qualifications. Staff consulted confirmed that they are encouraged to undertake vocational qualifications and specialist training to meet the changing needs of the people at the home is provided. The manager said that there is a programme of statutory training and covers First Aid, Fire Safety, Medication, Safeguarding Adults Challenging behaviour and Dementia Awareness. Overall, training records evidenced that staff have the skills to meet the changing needs of the people living in the home. Relatives present during the inspection were asked about the skills of the staff. One relative said that the staff know how to meet the needs of the people at the home and the other expanded on this response. It was stated that staff use a consistent approach and use tack when coaxing people to undertake tasks. Park Street Home For The Elderly DS0000008159.V373728.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): (31), (33) & (38) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. People at the home can expect to live in a safe environment and can be reassured that standards will be the subject of ongoing monitoring. EVIDENCE: Staff and relatives present during the inspection were consulted about the managers leadership style that maintained consistent standards. Staff said that the manager was approachable. Regular staff meetings and handovers Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 23 when shift changes occur were the systems used by the manager to maintain standards of care. Relatives said the manager and service provider were approachable and their suggestions are taken seriously. The home operates a Quality Assurance system through surveys. Surveys are sent to the relatives of the people living at the home and the respondents were satisfied with the standards of care provided at the home. The manager must consider other sources of feedback to ensure that the wishes of the people living at the home are reflected. Fire risk assessments are being undertaken to ensure the potential for fire is appropriately assessed and where appropriate preventative measures are introduced. The manager complies with other associated Health and Safety legislation that includes annual servicing of Gas Safety and Portable electrical equipment. It is the policy of the home that people living at the home make their own financial arrangements. It is the practice of the home to bill families for any expenditure. The fees range from 440.00 – 600.00 pounds per month. Park Street Home For The Elderly DS0000008159.V373728.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 2 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x 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 3 x 2 x x x x 2 Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 25 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 6 Requirement The Statement of Purpose must be reviewed to enable people to make decisions about moving into the home. The age range, admission procedure, the way dementia needs are met must be incorporated. Accessible formats must also be considered. The care planning process must be reviewed to introduce a more person centred approach to meeting needs. Individuals preferred routines, likes and dislikes must be incorporated. Social care needs must also form part of the care planning process. The communication needs of the person that describes the way decisions are made must form part of the care plan for people with communication needs. Risk assessments must be devised for activities that include an element of risk. Risk assessments that show locking the front door and the kitchen is consistent with the level of risk Timescale for action 30/04/09 2 OP7 12.3 31/05/09 3 OP7 12.2 31/05/09 4 OP7 13.4(b) 31/05/09 Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 26 5 OP18 13.6 6 OP29 7 OP29 Policies and procedures that show a commitment towards safeguarding people at the home must be formulated. 7,9 & 19 The manager must ensure that Sch 2.2(a) the staff employed are suitable to work with vulnerable adults. POVA First and CRB must be obtained for staff before they can work at the home. 7,9 & 19 Where possible written Sch.2.4 references must be obtained from the last or most recent employer. 30/03/09 28/02/09 28/02/09 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 Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Park Street Home For The Elderly DS0000008159.V373728.R01.S.doc Version 5.2 Page 28 - 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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