Inspection on 13/04/05 for Oakworth Manor

This inspection was carried out on 13th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Oakworth Manor 18/06/08

Oakworth Manor 19/06/07

Oakworth Manor 27/06/06

Oakworth Manor 15/12/05

Oakworth Manor 06/10/04

Oakworth Manor 18/05/04

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

CARE HOMES FOR OLDER PEOPLE Oakworth Manor Colne Road Oakworth Keighley BD22 7PB Lead Inspector Susan Knox Unannounced 13 April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Oakworth Manor Address Colne Road, Oakworth, Keighley, West Yorkshire BD22 7PB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01535 643814 01535 643814 Mrs Christine Lynn Flood Mrs Janet Kathleen Green Care Home only 21 Category(ies) of Old age (17), Dementia - over 65 (1), Physical registration, with number disability - over 65 (3) of places Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 6 October 2004 Brief Description of the Service: Oakworth Manor is located in the middle of the village of Oakworth a bus ride away from the town of Keighley. It is a detached adapted property set in its own grounds in the centre of the village of Oakworth. It is conveniently placed for local shops and a bus route. There are three separate communal rooms comprising of two lounges and a dining room. Bedrooms are located on the ground and first floor. Access to the first floor is by a stair lift. Accommodation is provided for twenty-one service users the majority are elderly. A small number may have mental health needs or/and physical disabilities. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. It started at 10 am finishing at 5 pm. The registered manager Mrs Janet Green was in charge of the home. Most of the day was spent talking to service users and staff, about standards of care and support at the home. The home had full occupancy. There were some staff vacancies; other staff was covering these shifts. A number of records were inspected. These included plans of care, administration of medication, staff recruitment and food hygiene. Information about the inspection findings were given to Mrs Green at the end of the visit. A list of requirements identified from this inspection can be found at the end of this report. What the service does well: What has improved since the last inspection? The majority of the building work is completed and minor works to upgrade facilities continues. The lounge and dining rooms provide very comfortable accommodation for service users and there is more space for visitors. Many bedrooms have been upgraded to good effect. A new nurse call system has been installed enabling service users easy access to summon help in all areas of the building. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 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 standard(s) 2 & 4 Progress has been made to ensure that service users rights of occupancy are maintained. The home has tried to carry out full assessments before admission so that individual needs can be met. EVIDENCE: rivately funded contracts of terms and conditions have been amended to include the number of the bedroom allocated to individuals. This was recorded in the contract. This document was signed on behalf of the service user by a relative. A number of service users were spoken to but unable to recall these details. Local authority funded contracts were also available. Three sets of care records were looked at. Files are kept for each service user and full pre admission assessments were recorded in all but one. The manager explained that this admission had been sudden and some details had not been made known to the home. As discussed, emergency admissions can be accepted provided full assessment details are given to the home. This issue was not entirely the home’s fault and the manager has referred it to the Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 9 placing authority. However, sudden admissions should not be accepted unless the social worker requests this as an emergency. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9, 10 & 11 Care plans are in place and regularly reviewed but the records should show service user/representative involvement. No progress has been made to ensure that risks associated with falls are referred to other agencies for advice. Medication systems were in good order. Respect and privacy is afforded to service users by staff but is compromised by a lack of screening in shared rooms. EVIDENCE: Each service user has a plan of care and three were reviewed. Care plans include risk assessments. Two service users were having a series of falls and this was one of the reasons for admission to residential care. Although the falls were identified in risk assessments and referred to in care planning, no further action had been taken to address the issue. The manager was advised to discuss these issues with the GP and/or the district nurse for advice and possible referral to a falls clinic. This had been discussed at the last inspection. Care plans were up to date and reviewed monthly. Although service users or representatives signed other documentation, care plans did not show this involvement. This is required to show that the plan of care has been drawn up with the agreement of service users or representative. Service users were Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 11 unable to confirm their understanding of care documentation. Staff confirmed that they sat with service users and discussed with them their preferences. Annual reviews include service users and representatives. Medication is administered via a monitored dosage system. The manager is pleased with the system and service provided by the pharmacist. At the time of the visit one service user administered own medication. This was recorded on medication records, these were checked and found to be satisfactory. Discussions were held with service users about medication. One advised that no eye drops had been administered that morning. The manager confirmed that this was nightly treatment only and this was evidenced in medication records. Service users said they were happy about staff procedures relating to respect and privacy. It was noted that staff were careful when attempting to reorientate individuals to their surroundings. The screening between beds in shared rooms is inadequate or missing. This compromises service user’s privacy. Since the last inspection care planning has been amended to include issues about death and dying. The staff have worked well in attempting to deal with this very delicate subject. The service users last wishes are ascertained where possible and this was evident in acquiring their or representatives signatures. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 & 14 Visitors are made welcome in the home and links are maintained with the local community. Mealtimes are well conducted and staff immediately pass on comments from service users. The home was aware and taking steps to address the issues arising from the timing of meals. Further choice for service users could be promoted if daily menus were displayed and alternatives offered. EVIDENCE: Service users and staff confirmed that visitors were made welcome. The new lay out of lounges has improved facilities for service users and their visitors. Some use the table in the lounge to join in a game of bingo with their relative. Staff confirmed that good links are maintained with the local community such as the church and schools. The main meal of the day was taken with service users. This was well managed and the dining room provides a very pleasant setting. Tables were laid appropriately. Staff withdrew at times and the meal was at a leisurely pace, with no one rushed. Staff were obviously aware of those with larger appetites than others. Therefore, no one was out faced. However, no menus were displayed and no choice was available therefore service users ate the meal provided. No one complained about the quality of meals other than on the day of the visit some of the meat was tough. Staff immediately referred this to the Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 13 manager. Other than this, the meal was tasty. Service users were asked about extra portions and additional drinks. Staff confirmed that discussions have recently been held about the issues arising from those having a late breakfast. Due to choice of bed times, late risers can not always enjoy full meals midday. Changes are being considered. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Information is available about the procedure for making complaints. Staff report concerns to senior staff to make sure that service users complaints are listened to. The procedures relating to abuse are discussed with staff and once the local authority training is received, the staff will know how to follow correct procedures in dealing with any suspicion or allegation of abuse. EVIDENCE: A complaint procedure is displayed in the hall for service users and visitors to see. In addition, this is included in the statement of purpose and service user guide. The service user guide is given to every prospective new admission or representative. The manager advised that no complaints have been made. No complaints have been received by the CSCI. During the inspection, it was evident that concerns raised by service users were passed to senior staff. This was confirmed in discussions with staff. Service users who were able said they would speak to staff or relatives about concerns. The local authority Adult Protection procedures were available in the office. The manager was aware of her responsibilities and staff confirmed that issues relating to abuse had been discussed. One member of staff confirmed that this was included in the induction training. The manager has approached the local authority in order to access adult protection training. She is waiting confirmation of dates. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 22, 24, 25 & 26 A significant number of improvements have been made to the environment thus ensuring comfort and pleasant surroundings for service users. In addition, many of the improvements have enhanced the safety of service users. The outstanding issues, once resolved would further improve safety and privacy. EVIDENCE: Since the last inspection, the providers have continued to complete the building work and up grade other areas of the home. A new nurse call system has been installed to all areas. An alarm is available in all bathrooms, WC’s and at each bed. The alarm can be clipped to each pillow. This was considered a great improvement by service users and staff. A separate sluice is now available although the area has to be decorated and new flooring fitted. The manager was advised to clear clutter so that staff could reach the wash hand basin. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 16 The issue of heating in part of the building (the building has two different heating systems) has been resolved. The manager advised that the providers are considering installing new heating in this part. Hot water temperatures are tested and recorded. Redecoration and upgrade of service users bedrooms continues to good effect. Issues still outstanding: • • • • Suitable bedroom door locks need fitting so that service users can lock doors. This should enable them to lock the door both inside and from outside and give staff access in case of emergency. Suitable screening between beds to ensure privacy of service users. Malodour in one particular bedroom. Confirmation from the provider that the Water Supply Regulations 1999 are met in the home. Cleanliness in the kitchen needs to be improved. The door to the storeroom needs replacing or cleaning. The storeroom was due to be cleaned and new flooring laid. The fridge and cooker hood needed cleaning. Records related to the food hygiene were not up to date. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 & 30 The recruitment of staff is not thorough and does not ensure the protection of service users. Staff training is ongoing. Up to date records are required in order to monitor any gaps in individual training and to provide evidence that staff are trained and competent in caring for the client group. EVIDENCE: There has been a change of staff since the last inspection. Three staff recruitment files showed that procedures varied. Progress had not been made following the last inspection when the manager was advised to obtain further references for one member of staff. In addition, due to an over sight no references had been obtained for a more recent recruit. In the three files, references were a cause for concern. The manager advised that all staff had submitted Criminal Record Bureau (CRB) forms she was awaiting clearance for the most recent. Records were available including CRB reference numbers. During discussions with service users, they were clearly happy with interaction with staff. It was said that staff were caring. Due to the turn over of staff, the numbers of staff with a NVQ level 2 qualification or equivalent has decreased. The manager advised that this training will recommence. The home is currently working through a training programme with a new agency. This was occurring on the day of the visit. Following this, a new staff induction will be introduced that meets the National Training Organisation (NTO) guidelines. Although training is on going as Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 18 confirmed during discussions with the manager and staff, training records were not up to date. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36, 37 & 38 The health and safety of service users and staff is met. Formal quality assurance systems are required to ensure that the delivery of a good care service continues to improve. In addition, staff supervision would enhance the quality of care. EVIDENCE: Service users and staff made positive comments about the staff team. It was evident from both direct and indirect observations that the views of service users are taken into account. No formal quality assurance of the service is carried out apart from annual reviews of care planning. Resident /relative meetings, anonymous questionnaires to service users, relatives and staff are all proven methods of ensuring service users views are heard. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 20 No formal supervision of staff takes place. This has been missing for some time. The manager and deputy have attended a supervision and mentoring course but say time restraints are affecting implementing the process. The outstanding issues from the last inspection in relation to health and safety have been addressed. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 x 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 x 3 3 x 2 3 2 STAFFING Standard No Score 27 x 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 1 x x 1 2 3 Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 22 yes 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. 2. Standard 3 7 Regulation 14 13 & 15 Requirement The manager must ensure that no admissions take place without full assessments Evidence is required to show service user. representative involvement in care plans. Repeated falls need referring to health agencies for advice. Display daily menus and offer choice for the main meal of the day. Ensure that staff attend the local authority Adult Protection training. Ensure adequate screening is available in all shared bedrooms. Ensure that appropriate door locks are fitted to bedroom doors. ( Previous timescale of 31 December 2004 not met) Check with the regulatory body regarding the compliance of services and facilities with the Water Supply Regulations 1999. ( Previous timescale of 13 December 2004 not met) Take steps to improve the malodour in one bedroom. (Previous timescale of 30 November 2004 not met) Improve the cleanliness in the Timescale for action 1 June 2005 1 June 2005 3. 4. 5. 15 18 12 & 16 12 12 12, 13 & 23 1 June 2005 1 July 2005 1 July 2005 6. 26 23 1 June 2005 7. 26 16 & 23 1 June 2005 Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 23 kitchen. 8. 9. 29 33 19 24 Ensure that two relevant references are obtained before employing staff. Ensure that quality assurance systems are introduced.( Previous time scale of 30 November 2004 not met). Ensure that formal supervision is implemented. ( Previous timescale of 30 November 2004 not met). 1 July 2005 1 July 2005 10. 36 18 1 July 2005 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 27 Good Practice Recommendations Ensure that staff training records are kept up to date. Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Oakworth Manor J52_S1166_Oakworth Manor_V220890_130405 Stage 4.doc Version 1.20 Page 25 - 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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