Inspection on 24/11/05 for Madley Park House

This inspection was carried out on 24th November 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

Madley Park House 07/11/06

Madley Park House 09/06/05

Similar services:

St Vincents

Heather House Nursing Home

The Cotswold Home

Fairways

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

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

CARE HOMES FOR OLDER PEOPLE Madley Park House Madley Park Witney Oxon OX28 1AT Lead Inspector Jane Handscombe Announced Inspection 24th November 2005 10:00 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 Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Madley Park House Address Madley Park Witney Oxon OX28 1AT 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) 01993 890720 01993 890724 manager.madleypark@osjctoxon.co.uk Order of St John Care Trust Patricia Just Care Home 60 Category(ies) of Dementia - over 65 years of age (30), Learning registration, with number disability over 65 years of age (3), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (60), Physical disability over 65 years of age (35), Sensory Impairment over 65 years of age (40), Terminally ill over 65 years of age (5) Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The total number of residents accommodated at any one time should not exceed 60. An application for registered manager must be received within three months of initial registration. 9th June 2005 Date of last inspection Brief Description of the Service: Madley Park is a care home providing personal care and accommodation for 60 older people. It is located on the outskirts of Witney in the centre of a housing estate and close to many amenities. The care home is provided by The Orders of St John Care Trust. The home is built in semi-contained care wings, which allows residents to relax in their own rooms, the lounge areas or the dining room. There is also a large central area on the ground floor known as the heart of the home which provides a friendly social area to residents for relaxing and entertainment. Attached to this area is a hairdressing salon serviced by a visiting hairdresser three times a week. There is also access to a pleasant, safe enclosed garden accessible for residents and their visitors to enjoy. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place on the 24th November 2005. The purpose of the visit was to see how the home is meeting the National Minimum Standards. The visit involved speaking to residents in order to ascertain their views upon the care and the services they receive at the home, speaking to the staff members and the manager of the home and viewing care plans and assessments whilst observing the general day-to-day operations of the home. The home presented as one, which was clean and tidy throughout. Residents were going about their daily activities in a calm relaxed manner. Staff were seen to provide care and support in an unhurried manner whilst respecting the residents’ dignity and respect at all times. Comments received from residents during the inspection included: • • • • • • • ‘The manager and everybody are very approachable’ ‘ The food is good, the food is nice’ ‘The bedrooms are very nice, comfortable and clean’ ‘When I came in I was made very comfortable and looked after very well’ ‘The care couldn’t be better’ ‘The staff are very good, very helpful’ ‘If I was unhappy about anything, I would go straight to the manager who would listen, she is very nice’ The inspector would like to thank the residents, their families and staff members for their assistance during this inspection. What the service does well: Residents spoken to during the inspection were complimentary of the staff and the care they receive at the home. Likewise they spoke positively with regard to the way in which the home was managed and both the residents and staff felt the manager runs the home in an open and inclusive manner. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 6 Staff were observed to interact with the residents in a manner that was thoughtful and considerate of their needs and the inspector gained the impression that the staff were a dedicated team, who were able to work together well and offer each other support when needed. Regular meetings are held for residents in which they are able to openly discuss any concerns or compliments that they may have regarding the care and facilities provided at the home. These meetings also provide a way in which the residents are able to keep updated on any issues regarding the home and to put forward any thoughts and ideas that may have. What has improved since the last inspection? 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. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3 Prospective service users and their families and representatives are given the information they require to make an informed choice about where to live. All residents undergo an assessment of need prior to moving into the home EVIDENCE: The home invites prospective residents to visit the home for a day, during which they are able to meet with fellow residents, meet the staff at the home who will be providing their care and assess the quality, facilities and general ‘feel’ of the place in order to make an informed choice as to its suitability. During the visit, the prospective resident undergoes an assessment of need to ensure that both parties are assured that these needs will be met. In situations where it is inconvenient for a visit to the home to take place, the manager undertakes an assessment of need at their place of residence. All residents are provided with written terms and conditions. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 9 The inspector noted one case in which there were no signatures within the assessment of needs to evidence that the service user had been consulted with and agreed to the contents, and likewise a failure of a signature to highlight that the assessment was undertaken by a person qualified to do so. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 and 9 The system of care planning is improved upon although these were found to be incomplete. EVIDENCE: The inspector viewed four residents’ care plans and found a number of issues running consistently throughout all those viewed, namely a lack in recording residents’ monthly weights and a failure to gain service users’ signatures to evidence that they have been consulted with and taken part in the assessment and care planning process; likewise the failure of gaining the assessor’s signature to evidence that they are qualified to undertake such a task. A requirement has been made within this report to ensure that residents’ files contain all the relevant details as specified in Schedule 3 of the Care Homes Regulations 2001, which was not always seen to be the case. The care plans viewed set out an individualised plan of care in which the residents’ needs had been identified and specified the action required to meet those needs. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 11 The inspector observed the medication round and found good practice taking place throughout. Photographs were found to be placed upon the medication administration records thereby reducing the risk of any potential accidents. Residents who wish to take responsibility for their own medication are enabled to do so within a risk management framework. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 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 the following standard(s): Not assessed on this occasion as all the above were assessed during the last inspection EVIDENCE: Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Policies and procedures are in place to safeguard residents from abuse. EVIDENCE: The home has a detailed organisational abuse policy and procedure. The manager is aware of the Oxfordshire adult protection procedures, and has distributed the booklet ‘Guidance for Staff’ to all staff at the home. The manager raises the awareness and the importance of the protection of service users from abuse in team meetings and supervisions. Information is also provided as part of the induction process for new staff. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21, 25 and 26 The home was purpose built and offers all the essential facilities required of a care home. The decor and furnishings are of a high standard and afford a comfortable and pleasant home for the residents. The home provides a pleasant, comfortable and homely environment for the residents. EVIDENCE: At the time of this inspection the residents were busy going about their daily activities and were observed using the attractive communal lounges that afford a choice of environments for them to enjoy. All areas of the home are cleaned to a high standard and there were no unhygienic odours present. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 15 The laundry was found to be clean and tidy although the cupboard, in which detergents, concentrates, etc are stored, was found to be unlocked. When mentioned to a member of staff, she immediately remedied the situation in order to protect the health and safety of the residents. It is recommended that tablets of soap found in bathrooms be removed in order to prevent the possibility of cross infection and wheelchairs be stored more appropriately so as to allow the residents access to the communal bathing facilities. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 30 A thorough recruitment procedure is followed to ensure, as far as is possible, the health, safety and well being of the residents in their care. EVIDENCE: Four members of staffs files were viewed which contained their recruitment, training and monitoring records. The recruitment procedures at the home were generally robust with clear monitoring systems in place to promote the protection of service users including application form, interview notes, references and Criminal Records Bureau (CRB) check being sought. A thorough recruitment procedure, based on equal opportunities and ensuring the protection of the service users is followed. All members of staff undergo induction training upon appointment to their posts, and are offered ongoing training which equips them to meet the assessed needs of the residents within the home. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 and 38 Madley Park House is a well managed home, run in the best interests of the residents using the service, with safeguards in place to protect their health, safety and welfare. There are clear robust systems in place to protect the residents’ financial interests. EVIDENCE: The manager has gained her Registered Managers Award and registration with the Commission for Social Care Inspection since the last inspection. She presents as a caring, competent and dedicated manager of the home, with a sound knowledge of the issues relating to the elderly. She is also clear of the management structure of the organisation and would know who to contact for support and guidance. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 18 Comments from both staff and residents around the management were positive. One member of staff informed the inspector that, ‘The manager is very approachable…I have a good working relationship with the manager.’ The inspector met with the administrator and discussed the management of the residents’ finances. Systems and records are in place and provide a clear audit trail to safeguard the residents’ financial interests. In the pre inspection questionnaire provided by the home it was clearly stated that all aspects of health and safety maintenance were appropriately completed. The CSCI is notified under Regulation 37 of The Care Homes Regulations 2001 of any occurrence affecting the welfare of service users, and the manager showed an awareness of what events need reporting. All accidents and incidents are recorded and monitored and appropriate action taken, including sharing the information with line management. Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 x x 3 x x x 3 3 STAFFING Standard No Score 27 x 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x 3 x x 3 Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 20 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 OP7OP3 Regulation 15 Requirement The registered manager must ensure that both the assessor and the service user or their representative sign all information within care plans appropriately. The registered manager must ensure that service users’ records contain all the relevant details as specified in Schedule 3 of the Care Homes Regulations 2001 Timescale for action 24/11/05 2 OP7 17(1)a 24/11/05 Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP21 Good Practice Recommendations The registered manager should discard soap bars in all communal bathing and washing facilities so as to avoid cross infection and the compromising of service users’ health and safety. The registered manager should make suitable arrangements for the storage of wheelchairs The registered manager should remind staff of the importance of storing hazardous substances safely. 2 3 OP19 OP38 Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Madley Park House DS0000062634.V254375.R01.S.doc Version 5.0 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!