LONDON BOROUGH OF HAVERING QUALITY ASSURANCE VISIT Residential & Nursing Homes and Domiciliary Care Services are registered and inspected by the Care Quality Commission. There is a responsibility on Local Authorities to ensure that local services are safe and provide value for money. The London Borough of Havering recognise this responsibility and is committed to ensuring that services delivered within its Borough are delivering good outcomes to Citizens and as such undertake regular Quality Monitoring visits to those services. The Adult Social Care Quality team has developed quality monitoring tools that will be used to evaluate the quality of services and produce information and sound intelligence for Citizens regarding the standard of services provided within Havering. The Council is committed to delivering high quality, cost effective services to Citizens whilst looking towards continuously improving its own performance. The providers will be expected to deliver safe, high quality services and will be expected to actively support a process of continuous improvement where quality and performance are enhanced. The Quality Assurance Monitoring report will be shared with providers to agree accuracy of content prior to being finalised. Name of Home: Date of visit: Address: Telephone number: Name of Registered Manager: Name of Registered Provider: Email Address: Total Number of beds: No. of Vacant Beds: No. of Havering Funded Service Users: CQC Rating Prominently Displayed: Name of Insurers: Insurance due date:
Revised 09/2015
Parkside 25th May 2016 65 Main Road, Romford, RM2 5EH 01708 743110 Yvonne Howson Romford Baptist Church Housing Association
[email protected] Registered for 32, maximum 30 0 5 Not yet inspected using the new rating system New India Assurance 3rd January 2017
1
1. GENERAL SUMMARY Parkside is a thirty two (32) bedded, three storey care home situated in Havering, providing accommodation and care for older people. The Manager stated that the maximum number of Residents accommodated at the Home is thirty (30). Most of the bedrooms have en suite facilities and those without have a wash basin in situ. It has well maintained gardens with off road parking for several vehicles to the front and side of the building. The Home is close to public transport links. At the time of the visit the Home had thirty (30) Residents. The accommodation is situated over two floors, however, due to the layout of the building there are stairs to access several areas on each of the first two floors. The lounges, dining room, laundry, hairdressing room, kitchen and Manager’s office are situated on the ground floor. There is a vacant self-contained flat on the second floor. The Manager, Chief Executive and Care Leader were available throughout the visit and were able to provide the requested information. The assistance of the Manager and the staff at Parkside is greatly appreciated.
2. ENVIRONMENT AND SAFETY & SUITABILITY OF PREMISES Cleanliness will be required as part of an overall package of care to support service users in the Home. The Service Provider ensures that the Home is maintained in good decorative order and any equipment or adaptations for daily living shall be maintained. Early indicators of concern - the home is dirty and shows signs of poor hygiene. Service Users’ desires to maximise independence and choice is balanced by minimising risk of harm to themselves or others. The Service Provider will ensure the health and safety of their care workers, service users and all visitors to the home. The Service Provider has policies on disposal of waste and control of infection. Early indicators of concern - the layout of the building does not easily allow residents to socialise and be with other people. Evaluation: People experience care in a clean environment and are protected from acquiring infections. People receive care in, work in or visit safe surroundings that promote their wellbeing.
At the time of the visit Parkside appeared to be generally clean and free from malodour and domestic duties had commenced. Where a slight odour was detected in one of the bedrooms, it was acknowledged that the domestic staff had yet to clean the bedroom. Hand sanitisers are available throughout the building. To enter the Home visitors are required to ring a bell and await access from a member of staff. Visitors sign in and out of the Home using the Visitors’ Book which is situated in the hallway together with any reports regarding the Home from, for example, the Care Quality Commission (CQC) and London Borough of Havering (LBH). Residents’ accommodation is divided over the ground and first floors. Most rooms have en suite facilities and those without have a hand basin in situ. The Manager stated that plans have been discussed with regard to potentially adapting two storerooms into en suite facilities for two of the bedrooms on the ground floor. Revised 09/2015 2
There is a main staircase with chair lift and fire escape staircase together with a passenger lift which accesses the first floor only. The Home has an enclosed garden which wraps around the back and side of the property which can be accessed from the corridor at the rear of the building. The garden is very well maintained and was specifically designed for people with dementia. The paths are ‘sprung’ and soft and made from recycled materials. There are raised planters and some have removable baskets in order that Residents can place planted flowers in their rooms. A raised pond contains fish and the Manager stated that one Resident has taken on the responsibility of feeding the fish and checking for any issues with the pond. The Manager stated that the Home is considering replacing the grass with astro-turf. Residents are growing vegetables in raised patches and planting and looking after hanging baskets. The garden also contains lots of seating areas, a summerhouse and barbeque. It is maintained by the maintenance person and a gardener visits once per fortnight. Corridors have handrails throughout and windows are fitted with restrictors. All radiators have covers. The building is currently accessed via the front door, however, the Manager stated that there are plans to convert the side entrance to become the main entrance. There are steps to the front door and once inside the building there are stairs to access the rest of the building but there are no stairs to access the ground floor from the side entrance. The corridor leading to the dining room has a small desk with computer equipment, the staff signing in book and staff fob signing in pad. The call alarm system screen is also situated in this area. The kitchen is accessed via a number key code and was not entered but was viewed from the doorway and appeared to be clean and uncluttered. There is a store room situated off the kitchen. All meals are prepared in the kitchen. There is a serving hatch from the kitchen to the dining room. The menu for the day is displayed in the dining room and is available in pictorial format if required. Daily temperatures for refrigerators and freezers are recorded. There is a small kitchen on the ground floor for use by Residents, staff or relatives with coffee making facilities and a refrigerator. It was observed that some produce in the refrigerator did not display appropriate stickers denoting when it had been opened. This was brought to the attention of the Manager who stated that some food items are brought in by family members or Residents. It is good practice to place stickers onto opened produce and the Manager may wish to consider introducing a system to accommodate this practice. The laundry room is number key coded and was entered and observed to be clean and well organised. The Manager confirmed that domestic staff collect washing from the laundry bags in Residents’ rooms and transport these to the laundry. Night staff are responsible for ironing clothes and clean clothes are taken back to rooms by domestics. Hanging clothes are transported using a hanging rail and folded clothing is placed in individual baskets. The Home appears to have sufficient washing and drying appliances and uses an auto dosing laundry system. The sluice room is situated within the laundry area. Revised 09/2015
3
There are three (3) lounges in the Home. The main lounge at the front of the building is used by the Residents but there are several stairs to access the room. There is a stair lift in situ. The Manager stated that discussions have been held at board level to install a platform lift access to the main lounge to encourage Residents to utilise this room more often. The second lounge which is called the garden room is situated off the dining room and contains comfortable seating, side tables and a television. There is a toilet and an activities cupboard in this room. A third smaller lounge or quiet room is also situated on the ground floor with seating and a table and has easy read guides for information on, for example, dementia, Parkinson’s disease, heart disease and Chronic Obstructive Pulmonary Disease (COPD). Bathrooms, wet rooms and toilets were viewed throughout the Home and were observed to be clean with soap dispensers and paper towels to help minimise the risk of cross infection. Call alarm cords were observed to be within reach. Toilets throughout the Home are gradually being replaced with comfort height toilets. Parkside has two (2) hoists, one on each floor. It was observed that these were serviced regularly with the next service due in June 2016. The Manager confirmed that at present there are no Residents who require the use of a hoist to transfer and that if any Residents did utilise a hoist then individual slings would be used. Residents’ rooms were viewed on both floors and all were observed to be clean and generally free from malodour. Parkside provides a wardrobe which is attached to the wall of the room for safety purposes and Residents are required to provide all other bedroom furniture. Residents are encouraged to personalise their rooms and where any decoration or replacement of carpets is required, this is completed in consultation with Residents. Rooms are identified by the number and a picture of the Resident. One Resident has chosen to have a doorbell which staff ring prior to entering the room. Refreshments were available and within easy reach of Residents in their rooms. The en suite toilets viewed were observed to be clean with no malodour. Call alarm cords / buttons were placed within easy reach in bedrooms and en suites. The Manager stated that as bedrooms become vacant fire door release mechanisms are being upgraded from the bottom of the door to the top of the door, the ‘anaglypta’ wallpaper is being removed and replaced with lining paper and carpets are being replaced with new carpets with a waterproof backing. Medication trollies are located on the ground floor and are appropriately locked and attached to walls. It was observed that the Medication Administration Record (MAR) sheets were stored on top of the trollies. The inappropriate storage of this personal information in a communal area was discussed with the Manager who immediately moved the MAR sheets to a secure location. A hairdressing salon is situated on the ground floor and the Manager stated that the hairdresser attends once per week, however, some Residents have their own hairdresser who also uses the salon. The second floor of the Home is a self-contained flat which is vacant. The flat consists of a bathroom, kitchen and several rooms. The Manager stated that discussions are underway with regard to the use of the flat. Revised 09/2015
4
There is good fire exit signage throughout the Home and fire exits are easily recognisable. There are no keypads to exit the building but all external doors have alarms which are activated when the door is opened. This information is fed to the system at the corridor desk and to staff pagers. There is a maintenance book where any maintenance that is required is recorded together with the date and response. Fire alarms and emergency lighting is checked weekly. Both systems were serviced in August 2015. Fire drills occur three-monthly and are recorded. The Home has a non-evacuation policy in the case of an emergency. Fire extinguishers were serviced in August 2015. Parkside has a planned and cyclical maintenance plan which records the location of the maintenance, the frequency, works requested, reasoning, suggested or recommended by, required source of funding, estimated cost, actual cost, agreed contractor and any further comments. Comment: In general a good level of cleanliness is maintained throughout the Home and the Home is kept free from malodour. Residents are generally well protected from acquiring infections. The Manager and Chief Executive have identified areas of refurbishment to be undertaken to maintain an environment that is in good decorative order. These have been presented to the board. All items stored in the small kitchen refrigerator should be labelled appropriately with opening and use by dates. The Home appears to maintain a safe and secure environment for Residents, staff and visitors and maintains robust health and safety records. Equipment is available to assist Residents where required to meet their needs. Parkside appears to have a friendly, relaxed atmosphere and the garden area is well maintained. The communal lounges and dining area provide comfortable seating in a pleasant environment. Residents are involved in decorating their bedrooms and preferences are accommodated where possible.
Revised 09/2015
5
3. STAFFING The Service Provider must have safe and effective recruitment procedures to ensure appropriate staff are employed. Staff recruited must be competent to carry out the tasks of caring for very vulnerable adults, including those who are confused and disorientated and/or who challenge the service. Two references must be supplied from the present employer and previous permanent employer. The applicant’s declaration with regard to any criminal convictions shall be obtained via the service provider’s application form. Managers/senior staff will have the relevant qualifications. Staff must be suitably trained to work with specific service users with ongoing training as necessary to meet the aims of the service. Details of all training, including induction must be kept on staff’s personal file. The service provider should monitor absenteeism and staff turnover. Consistent staffing should be supplied to support the overall continuity and quality of service. All staff, including temporary staff are suitable trained deployed and competent to offer the service. Suitable back up staff are available in the event of staff sickness or absences. Support staff should not work longer than a ten hour shift, with the exception of sleep-in staff. Awake night staff should not have worked for more than a maximum of 6 hours prior to arriving on duty. Early indicators of concern - Staff appear to lack the information, skills and knowledge to support older people/people with dementia. Evaluation: People are safe and their health and welfare needs are met by staff who are fit, appropriately qualified and are physically and mentally able to do their job. Staff (rota) Manager Duty Manager Carer Leader Carers Domestics Kitchen Maintenance Administrative Shift patterns:
Morning
Afternoon 1 1 1 2+2 3 4 1 2
Night
1 1
On shift at time of visit Yes Yes Yes Yes Yes Yes No Yes
Vacancies
2
07:00-20:00; 06:30-13:15; 15:15-21:30; 20:00-07:00
Induction programme: Regular supervision: Yearly appraisals: Recruitment / selection procedures in place: DBS checks: Employment / education references:
Yes
No
The Manager stated that staff vacancies are advertised through on-line employment sites, local media and by word of mouth. Applicants are required to complete an application form and are required to be trained to NVQ2 or above (or equivalent). Interviews are conducted by the Manager. The Home undertakes full checks including references and Disclosure and Barring Service (DBS). These are in place prior to staff commencing duties. Revised 09/2015 6
New staff commence an induction process which includes, but is not limited to, the organisation and its people, mission statement and values, policies and procedures, incident and accident reporting, and code of practice. Staff shadow more experienced members of staff on each shift and the amount of time spent shadowing is dependent on progress and previous experience. There is a three-month probationary period which can be extended if necessary. Parkside has a training matrix and the Manager stated that the Home is considering providing e-learning based training. The Manager has booked moving and positioning and infection control training for July 2016. Staff receive supervision every three months together with annual appraisals with sixmonth reviews. Staff responsible for medication receive a yearly medication observation review. All supervisions and appraisals are documented and inputted onto the electronic ‘Coolcare’ system. The system is able to flag up when the supervision was completed, by whom and when the next supervision is due. The Manager views all supervision forms and enters the information onto the system Staff sign in and out of shifts using a key fob and a signing in book which are located in the main corridor. The Manager stated that staff had been consulted with regard to shift patterns and had chosen to work long days. Shifts are 07:00-20:00 and 20:00-07:00 with two shorter shifts of 06:30-13:15 and 15:1521:30. The Home currently has vacancies for one (1) cook, one (1) kitchen assistant and one (1) bank staff. Parkside employs three (3) activities co-ordinators five (5) days per week, one of whom is seconded from a carer’s post. Domestic staff work from 08:00 to 14:30 and kitchen staff are available from 07:00 to 18:30. General maintenance tasks are completed by the maintenance person who works twenty five (25) hours per week. Two (2) administrators work Monday to Friday from 09:30 to 13:30 and 08:00 to 14:00 respectively. Sickness and holiday absences are covered from within the current compliment of staff and bank staff and agency staff are only used in emergencies. The Home utilises the same staff from the agency who are familiar with the Home and the Residents. Staff have attained or are working towards relevant qualifications. Care Leader meetings take place monthly and Carers’ meetings occur three-monthly generally one week after the Residents’ meeting. The most recent meeting was 7th April 2016 and minutes are emailed to staff and those without an email address are given a paper copy. Revised 09/2015
7
Kitchen and domestic staff also attend department meetings. Staff appeared knowledgeable of the needs of the Residents and were observed to be engaging appropriately with Residents. Staff spoken to confirmed that they receive regular supervision and appraisals and support from management and peers and undertake training as and when required. Comment: Parkside enjoys the benefits of a stable staff group. Staff absences are covered by the current compliment of staff, bank staff and in emergencies agency staff. Staff appear to be suitably trained, deployed and competent to work with the current needs of Residents. Ongoing training is being provided to meet these needs and the aims of the service. Details of this training are recorded. Staff appeared knowledgeable of the needs of Residents and were observed to be engaging appropriately with Residents.
4. RECORDING The service is planned and delivered in a consistent manner which respects and involves those using its service and supports the independence and safety of the service users. A Care Plan will be provided for all service users stating their support needs and outcomes required. People understand the care treatment and support choices available to them. The service provides information to help people who use services or those acting on their behalf, to understand their care, treatment and support, including the risks and benefits, and their rights to make decisions. Ensures that staff recognise and respect the diversity and human rights of people who use their services. Early indicators of concern - concerns about the way services are planned and delivered; concerns about the service resisting the involvement of external people and isolating of individuals; staff controlling of residents Evaluation: People can express their views, are involved in making decisions about their care, treatment or support, have their views and experience taken into account and have their privacy, dignity and independence respected. Files are stored securely within a locked cabinet in the corridor by the Manager’s office. Files were viewed and information is divided into clearly identifiable sections with an index. Sections include personal care; health; nutrition; communication; mobility; continence; activities / spiritual / cultural; emotional; and night care. The front of the file has Resident on admission details with a photograph. The Resident’s life history is documented and a gender preference form is signed together with a form stating that care plans have been explained. Where Residents are unable to sign for themselves, a reason why is documented for example, ‘I have hand tremors so my Revised 09/2015
8
keyworker signs for me.’ Care plans include the identified need, task, who will be involved, the desired outcome, a review date and are signed by the Resident where appropriate. Interim care plans are put in place where appropriate. Care plans are detailed and comprehensive for example ‘likes milky tea with one sugar’, ‘does not like spicy food’, and ‘requires food to be cut up into small pieces.’ Care plans are reviewed at the agreed review date which can be monthly or three-monthly. It was observed on one file that the review date was 12th May 2016. This was brought to the attention of the Care Leader who stated that the review would be completed in the month of May. The Chief Executive stated that specific staff have been identified to write and update care plans and training has been given and is scheduled. Mental capacity assessments for day to day decisions have been completed where appropriate. Deprivation of Liberty Safeguards (DoLS) documentation is also completed where appropriate. Information sharing consent forms were signed by the Residents. Risk assessments identify risks, detail the risk, provide an action plan and an agreed outcome. Falls records are completed where necessary. Visits from other professionals for example General Practitioner (GP), district nurse, dentist and optician are recorded and include the reason for the visit and the outcome. Medical consent forms are signed by the Resident together with influenza vaccine consent forms. End of Life wishes care plans are completed and cover all areas of care. Advance care planning discussions, preferred priorities for care and NHS advance decision to refuse treatment forms are completed and signed by the Resident. Files highlight any allergy information and file audit forms state that the files should be audited at least twice per year but it was evidenced that audits were completed monthly. Parkside utilises person centred software. Daily notes are completed on a hand-held electronic i-pod system. Each care and domestic staff member has an i-pod and is able to record any contact with a Resident onto the device which will upload onto the system via hotspots which are located throughout the building. Staff are able to record the type of contact, details of the contact, how long was spent with the Resident and the outcome. This information is stored securely and can be viewed on the system and printed if required. Notes viewed were observed to be detailed and comprehensive. Individual Personal Emergency Evacuation Plans (PEEPs) are completed and retained on files. PEEPs are reviewed quarterly or sooner if required. Comment: The service appears to be planned and delivered in a manner which respects and involves individuals and generally supports the safety of Residents. Revised 09/2015
9
Information was generally appropriate and detailed. Daily notes are recorded regularly and were comprehensive and informative. Comprehensive care plans are completed for all Residents stating their support needs and are reviewed regularly. End of Life care wishes were evident on the files viewed. Risk assessments are generally thorough, clearly identify risk factors and are regularly reviewed. The general layout of the files provides comprehensive detailing of likes / dislikes, preferences and social or other activities.
5. QUALITY OF CARE Services must be delivered in a professional manner, so that the identified needs of Service users are appropriately met. The Care Plan has a significant role in describing the services required, when they are required and evidences Service User/Relatives (as appropriate)participation in the process. Service User’s individual requirements are positively addressed and cultural diversity is respected. The welfare needs should include enabling service user to keep in touch with his/her natural community, racial identity and cultural heritage. Early indicators of concern - lack of activities or social opportunities for residents, lack of choice. Evaluation: People experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. People are supported to have adequate nutrition and hydration. Residents were observed to be wearing clothing appropriate for the time of year and appeared to be satisfactorily groomed. Breakfast is available from 08:00 with lunch served at 12:30 and tea at 17:30. Refreshments are available throughout the day. The menu for the day is displayed in the dining room with different choices available for breakfast and a choice of two main meals for lunch with dessert. Alternative meals are available if the Resident does not wish to have what is on the menu on a given day. The menu is varied and planned on a four-weekly rota with seasonal menus. Special dietary requirements are accommodated for example lactose-free, pureed and diabetic. Those Residents who are cared for in their rooms or choose to have their meals in their rooms are served first and meals are transported on trays with appropriate covers. Staff assisting with meal times wear appropriate aprons and Residents are offered tabards to protect their clothing. The lunch service was observed in the dining room and tables were laid with cloths, cutlery, glasses and condiments. One Resident chose to eat their meal in the garden room and was supplied with an over-chair table. Revised 09/2015
10
Meals smelt appetising, portion sizes were observed to be generous and there was little wastage. A choice of drinks was available with the meal. Staff were heard to ask Residents if they required any assistance. Where this was required, staff were observed to be seated next to Residents and engaging appropriately, for example a Resident was asked to test the food to ensure it was not too hot. Residents were complimentary regarding the meal. Refreshments are available in the communal lounge and in individual rooms and were easily accessible. The activities board is displayed in the garden room and shows morning and afternoon activities available for the day and other activities that are available. On the day of the visit there was a sensory activity quiz in the morning and card games in the afternoon. Other activities include ‘name that tune’, church service, colouring exercises, charades, bingo, board games and relaxation. Parkside also arranges for external entertainers to visit the Home and will accompany Residents to external events, for example to the local coffee shop or to the theatre. A board on the ground floor corridor displays pictures of Residents during a recent visit to the Home by Wild Science Pet Therapy. The Home benefits from a hairdressing salon and a hairdresser visits the Home once per week. Throughout the visit staff were seen to be engaging appropriately with the Residents and appeared knowledgeable of their needs. Residents spoken with expressed positive comments regarding the Home, for example: “All the staff are very nice here and I’m well looked after.” “I can go where I want and I can choose whether to stay in my room or sit down here. I have no complaints but if I did I would talk to the staff.” “The food is very good here and I have a nice room.” Medication Administration Record sheets (MARs) are completed and medication is checked and signed daily by the Manager or Care Leader. MARs appeared to be completed appropriately. Medication is ordered and checked by two members of staff when delivered, which is on a monthly basis. The distribution of medication is carried out by appropriately trained staff who wear a green tabard with ‘do not disturb, medication round in progress’. The locked medication trollies are appropriately secured to the walls on the ground floor. The medication refrigerator and the controlled drugs (CD) safe are situated within the key coded medication store cupboard opposite the Manager’s office. The refrigerator is locked and the temperature is recorded daily. The CD safe is locked and attached to the wall. The CD recording book is also situated within the cupboard and was appropriately completed. Revised 09/2015
11
The book tallied with drugs within the safe. A CD checking sheet is completed morning and night and signed by two members of staff. Parkside enjoys the benefits of having GP alignment with a local medical surgery and the GP holds a surgery at the Home once per week. Comment: Care is delivered in a professional manner and staff appeared to be knowledgeable of the needs of Residents. Residents generally appear to experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. Residents are supported to have adequate nutrition and hydration. Staff appeared sensitive to those Residents who required assistance and encouragement and provided this when requested in an appropriate and dignified manner. Medicines appear to be handled and administered appropriately to ensure the safety of Residents. Residents spoken to during the visit were generally positive and complimentary about the level and standard of care provided by the care staff.
6. IDENTIFICATION AND MANAGEMENT OF ABUSE All incidents of abuse or suspected abuse are detected and systems are in place to protect vulnerable Service users. Effective financial systems help protect service users from fraud or financial abuse and these systems are protected from exploitation. The Service Provider will have a written policy and procedure for the Protection of Vulnerable Adults in line with the Authority’s agreed Abuse Procedure, in all instances. Early indicators of concern - people do not have as much money as would be expected; staff or managers appear defensive or hostile when questions or problems are raised by other professionals; staff controlling of residents; members of staff use negative or judgmental language when talking about residents; people show signs of injury through lack of care or attention; people appear frightened or show signs of fear; behaviours have changed; moods or psychological presentation have changed; service not reporting concerns or serious incidents appropriately; managers appear unaware of serious problems with the service. Evaluation: People are safeguarded from abuse, or the risk of abuse, and their human rights are respected and upheld. All accidents and incidents recorded provide appropriate detail and appeared to be investigated with relatives informed as appropriate. Forms and additional paperwork are comprehensive. A falls incident report is audited monthly by the Manager.
Revised 09/2015
12
The Manager stated that they were clear that any safeguarding matters must be referred to the London Borough of Havering Safeguarding Team and appeared aware of the referral procedure. The Home has liaison and links with the Havering Safeguarding Adults Team. Staff spoken with were clear of the safeguarding policy and subsequent reporting lines. They confirmed that they understood the whistleblowing policy and felt they would be supported by management should the need arise to implement it. The Manager has applied to the London Borough of Havering for Deprivation of Liberty Safeguards (DoLS) Team for assessments as required. The Home manages Residents’ personal allowances. Each Resident has their own ledger on the Cool Care electronic system and there is also a paper version with income and expenditure that is double signed. Ledgers can be printed from the system. Money is not kept individually but the system can identify each Resident’s individual balance. The money is kept within a locked safe in the Manager’s office to which the Manager, Duty Manager and administrator have access. There are receipt folders for each Resident. Comment: Management appears to be clear on their responsibilities with regard to safeguarding issues. Staff have received relevant training and appeared to understand the signs of abuse and how the reporting process. Systems appear to be in place to protect vulnerable adults. Residents appear to be protected from abuse and the risk of abuse and their human rights are protected and upheld. Parkside has appropriate procedures for the handling of Residents’ monies.
7. QUALITY ASSURANCE Access to making a complaint is readily available to service users, in a format that is accessible to them. Complaints are responded to promptly in accordance with the Complaints Procedure. Service User feedback informs quality assurance. Early indicators of concern - systems are not in place to identify areas requiring improvement, audits of the service by the manager are not regularly undertaken. Evaluation: People benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety. Residents’ meetings take place three-monthly with the most recent meeting in April 2016. Residents are given a week’s notice of the date of the meeting and asked what they wish to discuss. The meeting is chaired by the Chief Executive and minutes are taken and made available. There are separate meetings for relatives which take place twice per annum. Complaints are recorded, investigated appropriately and responded to in accordance with the complaints procedure. Compliments are kept within the same file. Revised 09/2015
13
The complaints procedure and Resident meeting minutes are displayed on the Residents’ notice board on the ground floor. The complaints procedure is also displayed in the hallway by the front door. Each Resident has a communications book within their room which is used by Residents, relatives and staff to write any comments which can then be responded to. Surveys are sent out annually and the Home is in the process of collating the 2016 responses. The responses were viewed and generally the feedback was positive. The Manager completes monthly audits which include, but are not limited to, shift handover records, medication, care plans, nutrition, rotas, infection control, compliments and complaints, safeguarding, and supervision. Comment: Parkside views effective quality assurance as an important part of providing quality care and takes into account Residents’ and relatives’ opinions and concerns and aims to deal with these in a timely and appropriate manner. Complaints are responded to promptly in accordance with the Home’s complaints procedure. The provider has systems and processes in the form of audits to assess, monitor and improve the service provided.
8. POLICIES AND PROCEDURES Policy / Procedure Sent / received electronically Statement of Purpose Service User Guide Safeguarding Whistle Blowing Medication Complaints Recruitment
Available for viewing
Comments (if applicable)
The above policies and procedures were provided following the monitoring visit. Comment: The requested policies and procedures were provided and any relevant feedback concerning the documents will be fed back to the Manager outside of this report.
SUMMARY Parkside is able to provide accommodation and care for older people. The Home appears comfortable and has a friendly, calm and relaxed atmosphere. Revised 09/2015 14
The service provider has an ongoing redecoration programme in place and has submitted refurbishment plans to the board for agreement to ensure good decorative order is maintained and the building is adapted to suit the needs of Residents. Safety checks are carried out regularly and, in general, Residents experience safe and appropriate care and staff work in and relatives / friends visit a safe environment. A good level of cleanliness is maintained throughout the Home and Parkside is kept free from malodours. Hand wash, paper towels and disposable gloves are used in all communal bathrooms and toilets to help minimise the risk of cross infection. The garden area is very well maintained and Residents can access all areas safely. Parkside appears to enjoy the benefits of a stable staff group who are suitably deployed and competent to work with the current needs of Residents. Recruitment to vacant posts has commenced. Staff were observed to be engaging appropriately with Residents throughout the visit, they appeared knowledgeable of their needs and provided care in a dignified and respectful manner which supports Residents’ well-being. Varied, nutritious meals meet the specific nutritional requirements of Residents and a constant supply of refreshments is available. Where prompting and assistance with meals is required, this is provided by staff in a sensitive and dignified way. Care plans and recorded information were generally well arranged, detailed and comprehensive and the Home uses an electronic system to record information with regard to Residents which is easily accessible by staff and management. The Home has a system for gathering information about the service it provides and a process for evaluating that information and feeding it back into the service to assist in improving outcomes for Residents. The service is planned and delivered in a consistent manner respecting and involving Residents as appropriate which supports, promotes and encourages independence and safety. Residents spoke positively about the Home and said that they were satisfied with the care delivered at Parkside and that staff engaged appropriately and were helpful.
Report Written By:
Lisa Barker - Quality Officer
Name of Establishment Representative at the time of Visit:
Yvonne Howson - Manager Andrew Palmer - Chief Executive Diana Mfune - Care Leader
Date of Visit:
25th May 2015
Revised 09/2015
15
