Inspection on 27/06/06 for Oakworth Manor

This inspection was carried out on 27th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 15/12/05

Oakworth Manor 13/04/05

Oakworth Manor 06/10/04

Oakworth Manor 18/05/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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 Key Unannounced Inspection 27th June 2006 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.V296270.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. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 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 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.V296270.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 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 is adequate parking close to the building. There is level access available to the rear of the building and residents can easily access two patio areas from the lounges. 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. The current scale of fees ranges from £308 to £415 weekly. Additional charges are for chiropody and hairdressing. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Oakworth Manor is currently without a registered manager. The acting manager Ms J Blenkarn has been in post since September 2005 and is due to submit her registered manager’s application to be processed by the CSCI. A pre inspection questionnaire was sent to the acting manager to be completed with up to date information about the home in time for the inspection. This had been returned to the CSCI in time for the inspection. Comment cards were sent to three visiting professionals before the inspection and two were returned with positive comments about the care provided in the home. One inspector carried out this unannounced inspection between 09.00am and 5.30pm. The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard. During the inspection the inspector spoke to six residents, two visitors, six staff and the registered manager. The building was checked. Records were inspected including care plans, assessments, staff recruitment and training records, accident reports, financial records and health and safety records. Comment cards were also left with the home to be given to service users and sent to relatives. These were returned from residents and a relative in time for the report. The majority of the comments were positive and some have been incorporated into the report. During the visit, discussions with residents, a visiting professional and a relative showed that they thought the care provided in the home was good. What the service does well: What has improved since the last inspection? Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 6 The decoration and refurbishment of many of the bedrooms is near to completion to good effect. The residents liked their rooms and said they were comfortable there. The opportunity for residents to lock their bedroom doors to ensure privacy has improved with appropriate door locks fitted. Staff training has increased and will be of benefit to the residents in meeting their individual needs. The acting manager promotes staff training and regular activities in the home all for the benefit of the residents. 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.V296270.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 Oakworth Manor DS0000001166.V296270.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3. Quality in this outcome area is good. The judgement has been made that the Statement of Purpose/Service User Guide provides sufficient information so that existing and prospective residents are kept fully informed of the service but a copy should be given to each of them. The acting manager does ensure residents are assessed prior to admission. She is aware of the importance of keeping to the categories of registration so that the needs of the residents are met. Adjustments in procedures for communication are necessary to ensure that staff are fully aware of the individual needs of new residents. EVIDENCE: The Statement of Purpose and Service User Guide is a combined document that gives information to prospective and existing residents about the services and care on offer by Oakworth Manor. The document was available in the hallway with a label that gave permission to visitors to read it. A resident could not remember being given any written information about the home. The acting manager said that she does not automatically give out a copy. She was advised to give existing residents and/or relatives a copy of the Statement of Purpose/Residents Guide and one to prospective residents. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 9 In the care documentation for the four-service user’s case tracked there was evidence that all had been assessed before admission. The acting manager undertakes these visits. She had recently contacted the CSCI to request a variation in registration to admit someone outside the current registration. She was fully aware of the importance of admitting residents who have needs that can be met within the home. A visiting professional and a resident confirmed a pre admission visit to the home when time was spent with other residents and a meal was taken. The resident had viewed the allocated bedroom and felt comfortable there. Another resident also said that she had visited the home before moving in and was welcomed by staff. The deputy was working on care documentation for a recent admission. She was fully aware that she needed to discuss this with the resident but was also aware that she did not want to ‘bombard’ the resident with questions. A visiting professional confirmed that the proposed care plan had been discussed with the resident. Through case tracking and talking to staff, there was an understanding of a resident’s needs but the staff’s knowledge of particular disabilities could have been better. The admission was recent therefore other than the documentation provided by the hospital very little else was recorded. A short description especially the effect of a recent illness on short-term memory would have ensured that staff were alerted to the possible consequences. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 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, 9, 10. Quality in this outcome area is good. This judgment has been made using the available evidence and during a visit to the home. The care-planning format is in the process of change however the new one addressed the majority of resident’s needs. In order to fully protect the health needs of residents any risks identified must be followed by care plans. Residents and their representatives are not always given the opportunity to have their say. The residents are protected by the procedures for administering medication. Storage of the medication trolley should be more secure. Residents are happy with the way staff respect their privacy EVIDENCE: The inspector chose four residents to case track. The acting manager said that she was due to hold a meeting the following day with the intention of transferring care plans to a new format. The new format had been started for the latest admission and this was seen during the visit. However care plans could not be tracked for the other three residents chosen as care documentation had been archived. The care documentation files for the residents showed that a number of assessments had been carried out and were up to date such as moving and Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 11 handling, continence, skin viability and a general risk assessment relating to the environment. A nutritional assessment was partly completed in all three cases but needed further work. A sleeping assessment provided good detail about the individual needs of individuals during the night. For one service user the assessment about skin tissue viability judged there was a high risk. The manager was reminded that where any assessments conclude there is a medium or high risk then a care plan is required to try and reduce or eliminate the risk. One nutritional assessment included a reference to a social activity for no apparent reason. A Caring Assessment form had been completed with good detail about individual needs but the manager could not give a reason for introducing the form other than she thought it was needed. It is acknowledged that the acting manager has worked hard to introduce positive changes and these have worked to good effect. A format of care planning should be identified and adhered to as constant changes confuse staff and could lead to errors that could affect the care of residents. Care documentation should be streamlined and simple care plans introduced. Strengths, needs and actions for individual residents should be recorded after discussion with residents (if able) and/or relatives. Signatures should be obtained showing their agreement and involvement in care planning. These should then be reviewed every month or more frequently if needs change. This was discussed with the manager. One resident was aware that staff ‘kept records’ but was unable to confirm knowledge of care planning. More individual one to one discussions would raise awareness for those residents able to understand the reasons for record keeping. The care documentation showed that the health needs of residents was being met. This was confirmed in returned comment cards and discussions with residents and professionals. A letter was also available from a GP praising the care given to a patient requiring terminal care. The medication records and storage were checked. A monitored dosage system (MDS) is in place. A drug trolley has been purchased but there is no satisfactory place for secure storage. This has to be addressed. The recording of the administration of medication was satisfactory. Stock control checks can be carried out as the amount of tablets brought into the home is recorded. During the visit the deputy was recording the amount of tablets brought in by the latest admission. The senior care responsible for medication on the day said that no secondary potting up of medication took place. One resident was able to say she was happy with the way medication was given. Staff confirmed that they had had medication training and this was verified in the training records and training certificates. The community nurse was due to give a talk about the use of pain relief patches. The list of staff responsible for administering medication requires up dating reflecting the staff changes. Some jars of cream were seen in the store cupboard that had been partly used. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 12 These were not identified for individual residents. These should be disposed of and new containers used for one resident only. A visiting professional on the day of the inspection confirmed that discussions about the care package were carried out with respect to privacy and confidentiality. From observations carried out in a number of different communal rooms staff were caring. Interaction between residents and staff was good. Staff made attempts to ensure residents were dressed appropriately while at the same time respecting their wishes not to change. Staff spoke to residents at their level when they were seated and did not speak over their heads. One relative spent lots of time visiting the home and made positive responses in the questionnaire about consultations with staff in the home. Residents and a relative spoke positively about the care provided by staff. Residents confirmed that staff knocked on doors before entering and privacy and respect was given, for example during bath times. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 13 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, 13, 14, 15. Quality in this outcome area is good. This judgment has been made using the available evidence and during a visit to the home. There are organised activities taking place in the home. Visitors are welcomed. Residents said they had plenty of choice in daily routines and the majority enjoyed the meals. The provision of further choice would enhance the quality of the meals. EVIDENCE: On the day of the inspection the activity coordinator had rung in sick, therefore no organised activities were taking place. Normally she works 10 am to 4 pm Monday to Friday. However, staff were seen to spend time with individuals. They confirmed that regular activities take place. A number of visitors called and the manager said the home receives many visitors. Photographs were displayed in the home and showed the various events that had taken place such as an Easter bonnet competition. One resident said that she sat out on the patio when the weather was good. It was also confirmed that a local church representative visits the home monthly in order to provide a service. An outside entertainer also visits monthly. A resident confirmed that singers had visited the home the previous week. The needs of one younger resident have been met in care planning and it has been agreed that the activity coordinator will accompany her to the shops. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 14 During discussions with residents and staff it was confirmed that residents have autonomy in all daily routines. Residents said they could go to bed and get up when they wanted. They could choose to take part in events. One resident responded positively with a comment in a questionnaire by saying ‘I am thankful to be here around people I am happy.’ The main meal of the day was observed and it was noted that the food was presented well and looked appetising. One resident said there had been some staff changes in the kitchen and the quality of the meals were ‘hit and miss’. This was one comment only as the remainder of the residents enjoyed their food. Residents were able to eat their meal leisurely in a leisurely way and additional portions were offered. One resident who chose to remain in her room confirmed that she had enjoyed her lunchtime meal. The menus showed a well balanced diet and a good variety of choice was offered at breakfast. Choice was also offered for the main meal of the day but this was soup or sandwiches every day. Sandwiches were also available for the evening meal therefore this should be reviewed. A more definite choice would further enhance the enjoyment of meal times for residents. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is excellent. This judgment has been made using the available evidence and during a visit to the home. Residents are confident that any concerns will be listened to. An appropriate complaint’s procedure is in place. Service users are safeguarded as staff are trained in how to deal with allegations of abuse. EVIDENCE: The homes complaint procedure was displayed in the hallway near to the main door. It is also in the Statement of Purpose/Service User guide. A record is available to record complaints. No complaints about the home have been received by the CSCI. In the pre inspection questionnaire the acting manager said that one had been received and was pending an outcome. This was fully documented and was not about the care of residents. The residents spoken to had no complaints and one said she would go to the manager if she had any concerns. The manager and the majority of staff have attended the Adult Protection training arranged by the local authority. This was confirmed in discussions and certificates of achievement were seen. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 16 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. Quality in this outcome area is good. This judgement has been made using available evidence from the site visit that included a full building inspection. There is a good understanding of infection control procedures. The home provides a homely, clean and very comfortable environment although there is a shortfall that could potentially put service users at risk of harm. The last few radiators are to be guarded. Privacy for residents has improved but there are still some shortfalls such as the provision of a lockable facility and improved screening in shared rooms. EVIDENCE: A building inspection was undertaken during this visit. Many changes have taken place in the last two years and the environment has been greatly improved for the benefit of the residents. The drive to the house, car parking and patio areas has been finished to good effect and the gardens are well tended. The outside provides very pleasant, safe sitting areas for residents to enjoy the good weather. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 17 There are three communal rooms, two separate lounges and a dining room all comfortably furnished, well decorated and carpeted. The biggest lounge has ceiling fans fitted to help with temperature control. Both lounges have easy access to the patio areas. There is no passenger lift but a stair lift provides access to the first floor. Bedrooms are located on the first and ground floors. As the home was registered pre 2001 to the national Minimum Standards (NMS) only one has an ensuite WC. All bedrooms were well decorated and furnished. The majority had many of the resident’s own belongings displayed such as pictures and photographs. During discussions one resident pointed out familiar photographs. A few beds had hand grips fitted to help those less able. One room required the carpet replacing/relaying as it was not laid flat. Bed linen and curtains were of good quality. Many have had new vanity units fitted. The screening between beds in shared rooms did not ensure complete privacy. In order to achieve this screening should be fitted so that it surrounds each bed. All bedroom doors had appropriate door locks that can be locked for privacy by the resident but staff can gain entry in case of emergency. Still outstanding in some bedrooms is the fitting of appropriate radiator guards and a lockable facility. The acting manager said that the radiators were due to be fitted with guards. Each resident must have a lockable drawer or cupboard so that they can safely lock valuables or medication away if they self medicate. The door to bedroom 20/21 needs attention as it is not closing effectively. The home has two bathrooms one located on each floor. Both bathrooms have mechanical bath aids to help those less ambulant. A sluice is now located on the first floor. The home also has some separate WC’s. All these facilities had alarm calls and appropriate door locks to maintain privacy. During the inspection it was noted that cleanliness and odour control was to a very good standard. During discussions with domestic staff it was apparent that they had received appropriate training and were very familiar with the Control of Substances Hazardous to Health (COSHH) and Infection Control policies and procedures. They confirmed that they had achieved NVQ level 1 and 2 in Housekeeping. Some tablets of soap were left in bathrooms. Domestic staff were aware this should not happen. If residents prefer solid soap and soft towels these should be taken to the bathroom to be used and then returned to the bedroom. Paper towels and liquid soap were available in bathrooms, laundry and WC’s. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 18 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 quality of the outcome in this area is good. This judgement was made using available evidence including a site visit when documentation was inspected and discussions held with the staff on duty. The acting manager is aware about the importance of obtaining CRB and POVA checks of staff working at the home in order to protect residents. Further good practice during the recruitment of staff would enhance this protection. The acting manager and the staff have good attitudes and are clearly committed to training in order to provide a good standard of care. EVIDENCE: The home was well staffed on the day of this unannounced inspection. The person in charge early in the day was the deputy and the acting manager was working the late shift. A copy of the rota for the week of the inspection was made available and staffing levels were appropriate. Beside care staff the home is well staffed with ancillary workers. National Vocational Qualification (NVQ) training is on going. The requirement is to have 50 of care staff with level 2 or above NVQ qualifications. There has been a recent change in staffing resulting in a reduction in the percentage of care staff having achieved NVQ level 2 training, this level is now at 33 of the total staff team. This will shortly increase as two care staff are due to complete NVQ level 2. One person has achieved level 3 and another one is due to complete this level. A NVQ assessor was in the home on the day of the inspection. Staff confirmed NVQ training during discussions and this was also evidenced in certificates of attainment. Residents confirmed that staff were Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 19 caring. From observations during the visit staff displayed a good attitude and were seen to be observant of those requiring extra care. Recruitment files for the latest four members of staff were checked. Application forms had been completed and two references sent for in all cases tracked. All had received references from the most recent employer. In one case this was not a care post although there had been care experience undertaken previously. As good practice and in order to protect the residents, a request for a reference should always be sent for where employment has been in a care home/agency. In addition, the applicant’s last 10 years of work experience (where applicable) should be ascertained. The acting manager is aware of the importance of protecting the residents and ensures that Criminal Bureau Records (CRB) is checked before employment. She has contacted the CSCI in order to discuss the employment of staff before CRB clearance is received. This was due to low staffing levels if staff could not be recruited immediately. Copies of the Protection of Vulnerable Adults (POVA) first checks were available in files. In addition the staff are supervised as required until clearance is received. Staff terms and conditions were available and there was evidence that the General Social Care Council’s (GSCC) Code of Conduct and the Staff handbook had been given to staff on employment. This documentation ensures that care staff are aware of expectations relating to their care of vulnerable people. It was evident from the records and in discussions with staff that new staff receive a good induction into working in the home. This includes health and safety such as fire procedures. In addition it refers to resident’s privacy and independence. Staff confirmed that the induction gave them a good basic understanding of the home’s practices, policies and procedures. Staff also confirmed that other training was ongoing such as moving and handling, infection control, healthy eating and food hygiene. Training about abuse and the protection of vulnerable adults had been attended. Staff were aware that they had been booked to attend a dementia course and Adult Protection. It was evident that training is encouraged in order to fully meet the needs of residents and protect them. Training was reflected in the good practices observed during the inspection. Staff carrying out moving and handling techniques were observed to meet current policies and procedures. They explained their intentions to the resident. One wheelchair was in use without footplates. This was explained as being the resident’s choice. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 20 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, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including the site visit, PIQ and discussions and observations. The acting manager is striving to achieve the required qualifications and her management abilities are said to be good. The providers submit evidence that they monitor the home this report should include discussions with residents so that their input is taken into account. Some maintenance records were not seen. These are required to ensure the health and safety of everyone in the home. Improved QA systems are required so that the outcomes for residents can be measured effectively. EVIDENCE: The acting manager has been in post for 9 months and in that time has completed the NVQ level 3 in care. She is booked to start NVQ level 4 and the Registered Manager Award (RMA) in September 2006. She is near to completing all the documentation required in order to apply to be the registered manager at Oakworth Manor with the CSCI. This information was Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 21 seen during the inspection. Although lacking the required qualifications at present there is a commitment to meet this requirement under the National Minimum Standards (NMS). At the time of the inspection the acting manager was planning to work different shifts in order to understand the different issues that arise at times. Staff and residents spoke well about her management qualities. Minutes were available of staff meetings. Residents meetings are planned for the near future. The provider submits monthly reports to the manager and the CSCI as required. A representative of the provider visits the home weekly. The last three reports do not include reference to discussions with residents. The manager confirmed that this does happen. This should be recorded. Quality assurance (QA) within the home was discussed and although resident and relative surveys have been done in the past QA systems must be improved. Systems must be introduced that will measure outcomes for residents in all levels of care within the home. In the Pre inspection questionnaire (PIQ) completed by the acting manager a number of policies and procedures were missing. A number were identified as being in place during the inspection. Outstanding are emergency and crises, action to take in case of an accident and management of resident’s financial affairs. The manager said that she deals with no service user’s personal allowances. Two residents confirmed that relatives deal with their finance. The new manager has undertaken supervision training and regular supervision of care staff is ongoing. These records were available for inspection. Accident records are kept in individual care folders. The acting manager audit’s accident reporting monthly. This is good practice. The records for fire safety checks were checked. The fire bell and emergency light testing is carried out weekly. Staff fire drills are held monthly. These were recorded with the names of those staff that attended. Staff confirmed this during discussions. Health and safety within the home was well maintained with some omissions. The manager said that maintenance staff were undertaking long distance training in health and safety. Maintenance records were seen and were up to date. Outstanding were checks related to gas safety, an electrical wiring certificate, central heating and the nurse call alarms. Copies of these checks must be submitted to the CSCI. The tyres for one wheelchair required additional air. Ensure that resident’s wheelchairs are regularly maintained and records kept. One bedroom door Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 22 required attention in order to close effectively. When staff decant hazardous substances goggles to prevent injury from splash back must be provided. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 23 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 24 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 Standard OP1 OP7 Regulation 6 15 Requirement Provide existing and prospective residents and/or relatives with the service user guide. Ensure that care plans are in place for all residents. Include residents and/or relatives in care planning. Where risk assessments identify a risk a care plan is required. Streamline and simplify paperwork. Ensure there is secure storage for the medication trolley. Ensure that topical applications are used for one resident only and disposed of when no longer required. Up date the list of staff specimen initials for those able to administer medication. Ensure adequate screening is available in all shared bedrooms. (Previous timescale of 31 December 2004 not met) Ensure appropriate lockable facilities are available for each resident such as a drawer or cupboard. Ensure a more varied choice is DS0000001166.V296270.R01.S.doc Timescale for action 31/07/06 31/07/06 3 OP9 13 31/07/06 4 OP10 12, 13 23 31/07/06 5 OP15 12 31/07/06 Page 25 Oakworth Manor Version 5.2 6 7 8 OP28 OP31 OP33 19 9 24 9 OP38 12, 13 made available for the main meal of the day. Ensure that 50 of care staff have a qualification of NVQ level 2 or more. Ensure that the manager has a qualification of NVQ level 4 and RMA. Ensure there are effective quality assurance systems in place. Include the views of residents in monthly reports. Ensure that radiator guards are fitted where necessary. Replace the missing intumescent strip to one fire door. Ensure that no tablets of soap or soft towels are left in bathrooms. Ensure that the bedroom door closes effectively. Relay/refit the uneven carpet in one bedroom. Provide policies and procedures on emergency and crises, action to take in case of an accident and management of resident’s financial affairs. Submit evidence of checks related to gas safety, an electrical wiring certificate, central heating and the nurse call alarms. Ensure that resident’s wheelchairs are regularly maintained and records kept. Provide goggles for staff who decant hazardous substances. 31/08/06 30/09/07 31/08/06 31/08/06 Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 26 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 Staff references should be requested from previous employers in care homes/agencies as applicable. Ensure that prospective staff provides a previous 10-year work experience CV. Oakworth Manor DS0000001166.V296270.R01.S.doc Version 5.2 Page 27 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.V296270.R01.S.doc Version 5.2 Page 28 - 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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