Inspection on 15/12/05 for Oakworth Manor

This inspection was carried out on 15th December 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 13/04/05

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 Oakworth Manor Colne Road Oakworth Keighley West Yorks BD22 7PB Lead Inspector Susan Knox Unannounced Inspection 15th December 2005 09:00 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 Oakworth Manor DS0000001166.V272696.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. Oakworth Manor DS0000001166.V272696.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Oakworth Manor Address Oakworth Manor Colne Road Oakworth Keighley West Yorks BD22 7PB 01535 643814 01535 643814 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Christine Lynn Flood Mrs Janet Kathleen Green Care Home 21 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (17), of places Physical disability over 65 years of age (3) Oakworth Manor DS0000001166.V272696.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th April 2005 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 DS0000001166.V272696.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. It started at 9 am finishing at 3.30 pm. The acting manager Mrs Jenny Blenkarn was in charge of the home. She had been in post since September 2005. Most of the day was spent talking to service users and staff, about standards of care and support at the home. A number of records were inspected. These included plans of care, medication, staff recruitment and fire safety. Information about the inspection findings was given to Mrs Blenkarn 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? Staff said that social funds were now available for the service user’s activities. The acting manager has started to audit service user accidents monthly in an attempt to prevent reoccurrences. Risk assessments have been started in service user bedrooms. Procedures are in place for infection control. Staff attendance at training including Abuse and NVQ. The employment of an activity coordinator has led to positive feedback from relatives. Oakworth Manor DS0000001166.V272696.R01.S.doc Version 5.0 Page 6 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. Oakworth Manor DS0000001166.V272696.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 Oakworth Manor DS0000001166.V272696.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, 3, 5. The documents available about the home ensure that sufficient information is available for people to make a judgement before admission. The manager has tried to carry out full assessments before admission so that individual needs can be met. Pre admission visits to the home are encouraged. EVIDENCE: The Statement of Purpose and Service Users Guide are contained in one document. The manager confirmed that this had been updated to include the change in manager. The acting manager confirmed that she had carried out pre admission assessments. This information was available in care documentation. One had sufficient information to judge if the home could meet this individual’s needs. The other had insufficient information. The manager explained this was difficult to obtain. Oakworth Manor DS0000001166.V272696.R01.S.doc Version 5.0 Page 9 Service users confirmed that they were encouraged to visit the home and stay for a meal before making a decision to move in. This was also confirmed in discussions with staff. Oakworth Manor DS0000001166.V272696.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): 7-10. Service users were happy with the care given. Their privacy is respected in most instances other than effective door locks. Further work is required in care planning and the records of administration of medication in order to ensure that individual needs of service users are met and they are kept safe. EVIDENCE: The acting manager has been in post for a few months. Therefore the majority of care planning had been formulated before her time. She said that care plans were being updated. One long-standing care plan was discussed as needing urgent up dating, as aggression was not referred to in the care plan. Two sets of care documentation were reveiwed of admissions in the last two months. Care plans were in place in both cases. For one admitted in the week before the inspection some records were incomplete. One had diet-controlled diabetes but this was not referred to in a care plan. Good details were recorded about a GP visit. The staff were advised that some records were being duplicated for no purpose. Oakworth Manor DS0000001166.V272696.R01.S.doc Version 5.0 Page 11 The majority of the records were dated and signed. However, one moving and handling assessment indicated ‘ongoing review’. A definite date is required, if not recorded; the issue will not be reveiwed. The records showed that other health agencies such as the GP and district nurse are contacted for advice. The service users spoke well about the care provided in the home. The acting manager has attended and completed a medication course. Other senior care staff are enrolled to attend in January 2006. The manager has requested that a drugs trolley is provided as the present method of storage has limited access. The home administers medication via a Monitored Dosage System (MDS). The method of administering to individual service users was to good practice guidelines and staff wear protective gloves. There was a list of staff names, signatures and initials trained to administer medication. A record was available of medication returned to the pharmacist when no longer required. The manager had noted some errors in booking medication into the home and was intending to discuss this with staff. This was medication brought into the home separate to the MDS. Staff must copy the exact details from the label printed by the pharmacist to the Medication Administration Record (MAR). Staff were also advised to speak to a GP about altering the AM timing of medication for someone who prefers to stay in bed. It was noted that staff respected service user’s privacy by talking to them discreetly and knocking on doors before entering rooms. The locks to some bedroom doors did not work effectively. Care documentation included the service user’s preference for how to be addressed. Oakworth Manor DS0000001166.V272696.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): 12, 15. Activities are provided for service users that suit their preferences and abilities. Service users enjoy their meals and choice is available. EVIDENCE: A full time activity coordinator is employed. This is a new post that has benefited service users. This member of staff has attended a course in activities and reminiscing. She keeps records of service user’s interests and submits one to be kept in the care file. She said that one to one personal tasks are carried out in a morning such as nail care and hand massages. Seasonal activities has been card making and decorations. Service users said that they enjoyed bingo and board games. A Christmas party had been arranged and this included entertainers. A local school had visited with the children singing carols for the service users. The main meal of the day was not observed but staff confirmed that choice was available for this meal. This had been an issue at the last inspection. Service users and staff said the quality of the meals was very good. Oakworth Manor DS0000001166.V272696.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): 16, 18. The complaint procedure is readily available for anyone wishing to make a complaint. Procedures are in place for dealing with possible abuse. Training has helped staff to understand what action to take in order to protect service users. 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 acting manager said that no complaints were on going. Discussions were held with staff as a group and all confirmed that any concerns would be referred to the acting manager. In discussions with service users none had any concerns. The acting manager was aware of adult protection procedures. Herself and one other member of staff had attended the local authority adult protection training and others were booked in to attend in January 2006. She confirmed that all staff are to attend. Staff confirmed during discussions their awareness about abuse, whistle blowing and adult protection. Oakworth Manor DS0000001166.V272696.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): 19-26 A clean and pleasant environment is provided for service users to live in. The provider ensures that redecoration and up grading are on going to ensure comfortable accommodation for service users. Some health and safety issues need urgent attention in order to fully safeguard service users. EVIDENCE: The drive leading to the home and to one side has been re-laid with tarmac to good effect. There is level entry to the side of the home via a ramp. Patio areas are easily reached from the lounges and provide very pleasant sitting areas for service users in good weather. They confirmed that these had been well used in the summertime. This home provides very comfortable communal areas for service users. There are two separate lounges and a separate dining room. All are well decorated, Oakworth Manor DS0000001166.V272696.R01.S.doc Version 5.0 Page 15 furnished and carpeted. Service users said they were very comfortable. The acting manager advised that lounge chairs are being replaced. A number of the bedrooms were inspected. The manager advised that a number of new beds had been purchased. Redecoration and re-carpeting had taken place and was ongoing. Some bedroom door locks were not working effectively. The manager was advised that in two bedrooms with unguarded radiators the surface temperature was considered to be a risk to service users and needed urgent attention. The manager had started carrying out risk assessments of each room and this is good practice. Unguarded radiators are a hazard and all must be checked to ensure the safety of the service users. One bedroom door required an intumescent strip fitted. In the majority of the rooms cleanliness and odour control was to a good standard. The manager has introduced additional procedures for staff relating to infection control. Each carried an alcohol spray to use after care is given. A separate sluice is now available on the first floor although the area has to be decorated and new flooring fitted. Clutter has been cleared so that staff can easily access the sluice. Hazardous cleansers had been left in this area. The door should be locked or a lockable cupboard provided to ensure the safety of service users. The manager is slowly replacing commodes to ensure easier cleaning. The manager was advised that non-slip flooring can be laid in bathrooms, WC and sluice rooms as this ensures better infection control. Cleanliness in the kitchen has improved although the cooker hood and WHB needed further cleaning. The manager said that the storeroom was due to be altered and is not used for daily storage, items stored there need disposing of or stored elsewhere. The large central heating boiler stored there will be removed. A dishwasher was due to be ordered and new deep fryers. Oakworth Manor DS0000001166.V272696.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): 27-30 The new manager has been proactive in arranging NVQ and other training for care staff in order that they can provide good care for service users. A review of the induction would ensure that this procedure is more effective. Recruitment procedures must improve in order to protect the service users. EVIDENCE: Duty rotas are maintained for all staff. The staff team comprises of the acting manager; senior care staff, care and ancillary staff. Staffing levels were appropriate for the numbers and levels of care required for service users at the time. NVQ training is on going. A changeover of staff in the last six months has meant that the percentage of staff with NVQ level 2 has fallen. All care staff are undertaking NVQ level 2 one has achieved level 2. This was confirmed in discussions with staff and in training records. The recruitment records for four staff were checked. Application and interview records were available. Care staff had received the Code of Practice for care workers. Staff confirmed that they had been given Terms and Conditions of employment. The procedure is for two references to be applied for but in one case two good references were received but this was after employment had started. In another only one reference had been obtained and this was from a member of Oakworth Manor DS0000001166.V272696.R01.S.doc Version 5.0 Page 17 family. The manager advised that forms had been submitted to the Criminal Bureau Records (CRB) for clearance. However, the new staff had started work before clearance was received and there was no record or date about the submission. This means that staff provide care to vulnerable service users before proper checks have been made. The new acting manager was advised that new staff should provide the names of two referees. One should be the most recent employer and/or from care work, if the employee is experienced. A CRB form should be submitted and details recorded. A POVA first check can be carried out once a CRB has been applied for and if this gives clearance as well as two positive references are obtained, the employee can start work temporarily until the CRB clearance is received. Staff said that the number of training courses had increased, many had been attended and more were planned. They have attended Infection Control, Moving and Handling, Food Hygiene, COSSH, First Aid, Dementia and Palliative Care. Records show that an induction is provided for new staff. All new staff complete an induction programme. This was confirmed in discussions with staff. The majority of the induction takes place during the first day of work. This does not provide the opportunity for information to be taken in by new staff. The manager was advised to review induction procedures. The standard advises that induction takes place within the first six weeks of employment. Oakworth Manor DS0000001166.V272696.R01.S.doc Version 5.0 Page 18 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): 31-38. The new manager is aware of her responsibilities but needs to be more thorough in the recruitment of care staff. The new manager is also aware of her responsibilities in health and safety. She has started to audit accidents. Staff must be made aware of their responsibilities by ensuring that footplates are fitted to wheelchairs. EVIDENCE: The acting manager has been in post since September 2005. She has attended a number of training courses including currently undertaking NVQ level 3. She demonstrated that she was aware of her responsibilities She has the best interests of the service users at heart. Staff confirmed that the number of meetings have increased and that service users and relatives had made positive feedback. An up to date public liability insurance certificate was displayed as required. Oakworth Manor DS0000001166.V272696.R01.S.doc Version 5.0 Page 19 The manager advised that she deals with no service user’s monies apart from one where there is an agreement with a relative. A record is available about this agreement. The new manager has undertaken supervision training and regular supervision of care staff is ongoing. Accident records are kept in care planning folders. The acting manager has started to audit accident reporting monthly. This is good practice. She was advised that three accidents resulting in skin tears caused during transferring a service user by wheelchair should not have occurred. These were before she was in post. The records for fire safety checks were reveiwed. The fire bell test is carried out weekly. Staff fire drills are held monthly. This was recorded and staff confirmed this during discussions. The manager advised that the testing of the emergency lights is carried out weekly but the record could not be located. Wheelchairs were seen to be used without fitting footplates. This puts the service users at risk of injury. Oakworth Manor DS0000001166.V272696.R01.S.doc Version 5.0 Page 20 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 3 3 2 Oakworth Manor DS0000001166.V272696.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 Standard OP7 OP9 OP10 Regulation 15 13 12, 13 23 Requirement Ensure that care plans address all the individual needs of service users. Ensure that staff administer medication in line with guidelines. Ensure adequate screening is available in all shared bedrooms. Ensure that effective 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) Ensure that all equipment and fittings are kept clean in the kitchen. Ensure that two relevant references and CRB/POVA first clearance are obtained before employing staff. Ensure that radiator guards are fitted where necessary. Replace the missing intumescent strip to one fire door. DS0000001166.V272696.R01.S.doc Timescale for action 31/01/06 15/01/06 31/01/06 4 OP26 23 15/01/06 5 OP29 19 15/01/06 6 OP38 12, 13 15/01/06 Oakworth Manor Version 5.0 Page 22 Ensure that wheelchairs in use have footplates fitted. 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 OP30 Good Practice Recommendations Review the current method and timescale for inducting new staff. Oakworth Manor DS0000001166.V272696.R01.S.doc Version 5.0 Page 23 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 DS0000001166.V272696.R01.S.doc Version 5.0 Page 24 - 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. 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