Inspection on 07/11/06 for Madley Park House

This inspection was carried out on 7th November 2006.

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 24/11/05

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 Philippa MacMahon Unannounced Inspection 7th November 2006 10:30 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 DS0000062634.V319598.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. DS0000062634.V319598.R01.S.doc Version 5.2 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) DS0000062634.V319598.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of residents accommodated at any one time should not exceed 60. 24th November 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 home is provided by The Orders of St John Care Trust. The accommodation is in semi-contained care wings that allow 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’ that 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 for residents and their visitors to enjoy. DS0000062634.V319598.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 10:30 and was in the service for five.hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. Of these, 11 relatives/visitors comment cards, seven “Have your say about Madley Park House”, and seven GP comment cards were received by the Commission. The inspector looked at how well the service was meeting the standards set by the government and ha,s in this report, made judgements about the standard of the service. The inspector was afforded a very warm welcome by both the staff and the residents. Care plans were examined and this was followed by meeting with individual residents to see if their care needs were being met. Discussion took place with the registered manager, operations manager, residents, staff, relatives and visitors to the home. The medication system was examined, a sample of staff files, including evidence of training and development that had taken place, residents’ files and the accounting system were also examined. Records required by regulation were examined. A tour of the premises took place. The inspector would like to thank all the staff who assisted in this inspection in any way for their co-operation. What the service does well: Madley Park Housee is most attractive, comfortable and well maintained. The quality of the furnishings and fabric are of a very high standard. The home is very well managed and there are clear lines of accountability and responsibility. DS0000062634.V319598.R01.S.doc Version 5.2 Page 6 The care plans clearly support the resident’s individual care needs, and the residents are well cared for. There is good communication with the GPs, district nurses and other health care professionals. The activities and social events provided offer variety and interest to match the needs of the residents. There are strong links with the local community. The home is able to meet the cultural, religious and racial needs of the residents. The home is well staffed and the staff are supported by their peers, senior staff and the registered manager. The staff-training programme in place is appropriate to the needs of the staff. The quality initiatives that are in place are excellent and reinforce the registered manager’s commitment to providing the best care for the residents. The Trust provides excellent working conditions for their staff, and support mechanisms. 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. The summary of this inspection report can be made available in other formats on request. DS0000062634.V319598.R01.S.doc Version 5.2 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 DS0000062634.V319598.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident has a thorough assessment of his or her care needs and assurance that the home is able to meet these. Prospective residents are given sufficient information to enable them to make an informed choice about where they wish to live. An intermediate care service is not provided at this home. EVIDENCE: A sample of care plans was examined by the inspector and each one was based on a comprehensive pre-admission assessment that is reviewed and updated in the first week following admission to the home. The registered manager carries out the pre-admission assessments and confirmation is given in writing to the individual that the home will be able to meet their care needs. Prospective residents are encouraged to visit the home and spend some time before they make a decision to move in. DS0000062634.V319598.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Every resident has a comprehensive care plan in place that is based on his or her assessed needs, reflects their individual care and is regularly reviewed. The residents are well cared for, feel that they are treated with dignity and respect and know that their wishes regarding the end of their life will be carried out. EVIDENCE: The inspector examined a sample of care plans and found them to reflect a good “picture” of the individual resident, their care needs and how these would be met. There was clear evidence of care plans being reviewed and updated on a regular basis and, in the sample examined, the residents or their representatives had signed that they had seen the care plans and agreed with the care to be provided. DS0000062634.V319598.R01.S.doc Version 5.2 Page 10 There are good communications between the staff and the GPs and district nursing staff. Seven GPs responded to the Commission’s comment cards and one said, “I believe Madley Park House provides a good standard of care for its residents”. The home has access to other health care services such as specialist nurses, pharmacy, opticians, dieticians and chiropodist. The inspector examined the medication systems within the home and found these to be in good order. A number of residents are able to administer their own medication and the home has in place a good system for ensuring that the residents are safely able to manage this themselves. Throughout this inspection it was apparent that the staff understood issues about privacy and dignity in that the residents were always assisted in a kindly and respectful manner, and by knocking on doors prior to entering a resident’s private room, or the bathrooms and toilets. The inspector noted that there was information in the individual care plans about the resident’s wishes concerning terminal care and arrangements after death. This information is usually obtained at the time of the initial assessment and is then reviewed at an appropriate time to ensure that this is still correct. DS0000062634.V319598.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The provision of activities and social events is excellent and matches the identified needs of the individual residents. From the evidence seen, and following discussion with the registered manager and staff, the inspector feels that the home will be able to meet the religious, cultural and racial needs of any residents admitted to the home. EVIDENCE: The inspector met with the activities co-ordinator who has been in post for only a few weeks. It is commendable that the registered manager included the residents in the selection process for the activities co-ordinator. The previous activities programme has been reviewed and is being further developed. One-to-one activities are being provided and, following admission to the home, new residents will have the opportunity to discuss their individual life style and chosen activities. The activities co-ordinator keeps a record of the activities taken part in and these will be reviewed to ensure that the programme is meeting their needs. Relatives and residents spoken to spoke very highly of the activities co-ordinator, and the varied and interesting programme that has been made available to them. DS0000062634.V319598.R01.S.doc Version 5.2 Page 12 A service of Holy Communion took place during this inspection and residents were invited to attend in a very sensitive manner by the care staff. The home is very much a part of Witney and a large proportion of the residents and staff are local and there is a strong sense of community and family in the home. Meals and mealtimes are an important part of the residents’ day and the inspector observed lunch being enjoyed by the residents. Those spoken to said that they had lovely meals and could choose what they had, and snacks were always available should they request it. Discussion with the registered manager took place and she said that they had developed feedback sheets for the residents to tell them about the meals and these had been very helpful in trying to attain consistency in the provision. The district nurses had also been helpful in recommending snack boxes and simple ways to fortify the food for those residents who required it. DS0000062634.V319598.R01.S.doc Version 5.2 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. 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. The home has an accessible complaints procedure in place. All staff are aware of the issues of the protection of vulnerable adults. EVIDENCE: The home’s complaints procedure is in place and accessible to residents and visitors to the home. A copy is displayed in the entrance hall, and is also contained in the Service Users’ Guide. The registered manager shared with the inspector two complaints that had been received in the service and how these had been dealt with. They had both been dealt with in accordance with the home’s procedure. The Commission has not received any complaints about the service since the last key inspection took place. The staff receive training in the protection of vulnerable adults, and there is an ongoing programme of awareness raising with all the staff working in the home. DS0000062634.V319598.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25, 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home offers the residents a comfortable, well maintained and attractive home. EVIDENCE: The inspector toured the building and found all areas to be cleaned and maintained to a very high standard. The fixtures and furnishings are of a high quality. The home was purpose built and offers a light and spacious environment with a number of communal areas for the residents to enjoy. The grounds are attractively laid out and in the summer months gave a great deal of pleasure to the residents and visitors. The maintenance co-ordinator is new in post and has a great deal of expertise in this field to support the registered manager in ensuring the safety and welfare of both the residents and staff. Regular checks are in place and documented accordingly. DS0000062634.V319598.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well staffed with appropriate number and skill mix across all shifts. The recruitment procedures are in place and offer protection to the residents. Training and development of the staff is in place and an ongoing programme is continually being monitored. EVIDENCE: On the day of the inspection the home was fully staffed, and the duty rosters seen showed that sufficient numbers and skill mix of staff are on duty at all times. A sample of staff files was examined and found to be in good order with all necessary checks having been made to ensure the protection of the residents. The inspector noted a useful interview score sheet and checklist in one of the new staff files. This is very good practice and is a useful tool to evidence decisions made about staff appointments. There is a good training and development programme in place and the Trust has just introduced an “E Learning“ induction training that is being rolled out across the Trust. The home has nearly achieved the target of 50 of all care staff having achieved a National Vocational Qualification Level 2 or 3. All senior care leaders are required to achieve a National Vocational Qualification Level 3 before they are eligible for the position. DS0000062634.V319598.R01.S.doc Version 5.2 Page 16 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, 35, 38. Quality in this outcome area is excellent. . This judgement has been made using available evidence including a visit to this service. The home is very well managed and there are clear lines of accountability, responsibility and good teamwork. The quality assurance tool in place and commitment of the registered manager to the outcomes is excellent. The health, safety and welfare of the residents and staff is promoted and protected. EVIDENCE: The registered manager is well qualified and experienced to manage the home. There are clear lines of responsibility and accountability in place and staff spoken to felt that they were very well managed and thoroughly enjoyed being part of the team. DS0000062634.V319598.R01.S.doc Version 5.2 Page 17 Residents, relatives and visitors commented favourably in the Commission’s comment cards and the “have your say about Madley Park document. The Trust has introduced a quality assurance system that requires managers to continually audit, monitor and report on all of the key management systems on a regular basis. An annual quality survey has recently taken place. It is recommended that a copy of the summary of the annual quality survey should be supplied to the Commission. As a result of the survey the registered manager has given the receptionist an extension to her role to enable 1-1 discussions with the residents to take place should they want it. The rationale for this is that the residents are given the opportunity to voice any concerns or issues before they become a big issue. This is for a period of three months in order to evaluate its efficacy. This is an excellent initiative and, coupled with the activities co-ordinator also giving 1-1 time, shows the home’s commitment to treating the residents as individuals. The inspector met with the home’s administrator and examined the way that the residents’ money and accounts are managed. These were found to be in good order with clear records that are auditable. All records required by regulation are in place and in good order. There has been a recent visit to the home by an environmental health officer who examined the kitchen and, as a result, issued an improvement notice that had been received into the home at the time of this inspection. The registered manager has already taken action to correct these omissions. The staff are aware of health and safety issues and receive mandatory training in fire safety, moving and handling and food hygiene. There is always a member of staff on duty who is qualified to administer first aid. DS0000062634.V319598.R01.S.doc Version 5.2 Page 18 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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 DS0000062634.V319598.R01.S.doc Version 5.2 Page 19 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. Standard Regulation Requirement Timescale for action 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 OP33 Good Practice Recommendations It is recommended that a copy of the summary of the annual quality survey should be supplied to the Commission. DS0000062634.V319598.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 DS0000062634.V319598.R01.S.doc Version 5.2 Page 21 - 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!