Inspection on 23/05/05 for Oldfield House

This inspection was carried out on 23rd May 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

Oldfield House 21/11/07

Oldfield House 11/05/06

Oldfield House 03/11/05

Oldfield House 10/11/04

Oldfield House 10/06/04

Oldfield House 23/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Oldfield House 15, Hawkshaw Avenue Darwen Lancashire BB3 1QY Lead Inspector Jennifer Turner Unannounced 23 May 2005 10:15 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. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Oldfield House Address 15, Hawksahw Avenue Darwen Lancashire BB3 1QY 01254 702920 01254 707418 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) Dr Govindon Asoka Kumar Mrs Kathleen Kumar Vacant Care Home only Personal Care 19 Category(ies) of Old age, not falling within any other category registration, with number (OP) 18 of places Physical disability (PD) 1 Male Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 A total of 18 (OP) elderly service users can be accommodated at the home. 2 One named service user who requires personal care and is under the age of 65 (PD) can be accommodated at the home. When this service user leaves the home, the Commission for Social Care Inspection must be contacted to remove this condition. 3 The home shall employ, at all times a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 10 November 2004 Brief Description of the Service: Oldfield House is a converted two-storey building set within its own grounds. There is car parking space at the front of the building. The home is situated about 200 metres from the main Blackburn to Darwen road where there are a variety of shops and retail premises. This road is a bus route. Darwen town centre is approximately one mile away. The home is owned privately and is part of a small local group of three homes. The home is registered to provide personal care within a residential setting for 19 residents, 18 places are for older people and there is one bed for a named resident with a physical disability. Accommodation is provided on two floors. There are 17 single bedrooms and 1 double bedroom. The home has one lounge and a separate dining room. Various adaptations to promote independence and assist mobility are located around the home. There are bathrooms and toilets upon each floor. Gardens are accessible to service users via a ramp. A passenger lift connects the two floors. Service users have access to all community health services. At the time of the inspection there was full occupancy. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 23rd May 2005. Information was obtained by talking with the acting manager, staff members, visiting professionals and residents, by examining a variety of records and walking around the home. Views were obtained from residents and staff on a variety of topics and information was also obtained by case tracking. No resident or relative comment cards were returned to the CSCI. Views have been recorded collectively where the answers obtained were similar. Any specific or differing comments have been recorded in the main body of the report. The inspector’s notes have been retained as evidence of the inspection. What the service does well: Staff at the home carried out a thorough assessment procedure prior to residents moving into the home on a permanent basis. Residents spoke about staff being kind and looking after them well. They said that their visitors were always made welcome. The majority of residents enjoyed the meals offered. Comments ranged from “meals are good” to “meals are alright”. The home was clean, safe and in good decorative order. Residents said they could talk to the staff or owners about any concerns they may have. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The production of an action plan, outlining how the registered person intends to meet the requirements made in the report, would ensure that the continued care of the residents, and development of the home is monitored and progressed. The acting manager must familiarise herself with the policies and procedures relating to medication in order to ensure that staff continue to administer medication correctly. Although there is a complaints procedure, it must include the address and telephone number of the Commission in order for residents and relatives to be aware of whom to complain to outside of the home if they wish to. Policies and procedures to safeguard residents from possible financial irregularities must be reviewed and held at Oldfield House and accessible to all staff. The registered person must ensure that water is stored at a temperature sufficiently high enough to prevent Legionella, thus ensuring the health and safety of the residents and staff. All information relating to staff must be kept in their individual files and held at Oldfield House for access for the inspector. Induction and Foundation training, that meets the NTO recommendations, should be offered to all staff in order for them to receive a sound base for their future training. The registered person must ensure that the acting manager becomes suitably qualified, is competent and has the required experience to manage the home. The registered person must ensure that visits under regulation 26 are carried out at least once a month in order to meet the legal requirement. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 7 Although staff said they received positive, verbal comments from visiting professionals and relatives, the homes own Quality Assurance methodology could be improved. Feedback from residents needs to be obtained and collated together on an annual basis. This information needs to be inserted into the Service Users Guide and made available to the inspector at inspection. The registered person must ensure that the Fire Risk assessment is reviewed on an annual basis. The registered person must ensure that all records relating to Oldfield House, including the residents and staff information, is retained at Oldfield House. 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. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 8 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 Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 9 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) 3. The home does not provide Intermediate Care. A comprehensive assessment procedure was carried out prior to people moving into the home. This meant that their needs were known and met. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 10 EVIDENCE: The acting manager had been in post since March 2005. She had not dealt with any admissions since she took over her new role. Four case files were examined. One was for the most recent respite care admission into the home. Pre admission assessments were provided by social workers, either from the local area or the hospital. The previous registered manager or Senior Care staff on duty also completed an assessment on arrival that covered all areas of this standard. These needed to be signed and dated by both the member of staff and resident, confirming that they agreed with any decisions taken. Information was also obtained from family members. All the information gathered was used as the basis for the care plan. Assessments supplied by District Nurses were recorded separately but the information was included within the main assessment. The acting manager said that a letter of acceptance was sent to prospective residents confirming that the home could meet their needs. One resident confirmed that they had received a copy. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 11 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;8;9;10 Resident’s healthcare needs were identified and met. Their personal care was delivered in a way that promoted residents’ privacy and dignity. The control of medication was well managed, promoting good health care. EVIDENCE: Individual care plans identified the full range of resident’s care needs. These were updated on a monthly basis and signed or marked by all parties involved. If residents were not able to sign a reference was made to this. Relatives were able to sign the plan if they had been present. Care plans examined showed that either residents and/or their relatives had been involved in the reviews. Risk assessments, relating to the prevention of falls were seen on residents’ case files. Some residents told the inspector that they “were included in their review”. Changes in care were reflected in the reviews. Care plans showed that residents’ accessed specialist services. Opticians, dentists and the chiropodist all visited the home, but residents said they were able to visit the practices themselves if they wished. The acting manager said that none of the residents had any pressure sores but the District Nurse, who Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 12 was present at the home, said that she was available to carry out assessments in respect of pressure areas and incontinence. The services of the Continence Adviser were also sought. An environmental assessment had been carried out by an Occupational Therapist and the report was made available to the inspector. Hearing Aids were checked at the Audiology Department at Blackburn Royal Infirmary. From walking around the home there was evidence that bathing and lifting equipment, ripple beds and pressure cushions were provided. Nutritional screening was carried out and records showed that two residents with weight problems were being monitored. None of the residents administered their own medication. There was evidence that staff who administered the medication had received appropriate training apart from the acting manager who still had to undertake accredited training and familiarise herself more fully with the policies and procedures relating to medication. Medication, including the Controlled Drugs, was checked. All were stored and administered correctly. The residents spoken with said that the staff were kind and looked after them well. They said that the staff considered their privacy and dignity – “they knock on my bedroom door before entering”. Their personal care was “carried out in private”. Staff said that they ensured that toilet and bathroom doors were closed when they attended to residents. The double bedroom had single occupancy and the acting manager indicated, “it would be screened if used as a double”. A member of staff explained how residents’ privacy and dignity was respected. Residents said that their visitors could speak with them in the privacy of their rooms if they wished. Locks were seen on bedroom doors and there was a locked drawer in bedside cabinets. Some residents said that they used them; others said they “didn’t bother”. A pay telephone was sited at the far end of the hallway near to the lift, but a mobile telephone was available for telephone conversations to take place in private. There was evidence that there were telephone sockets fitted in some bedrooms. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 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 standard(s) 12;13;14;15 The dietary, social, cultural and religious needs of residents were met. Residents were able to make choices so that their lifestyle met their preferences. Social contacts were maintained. Meals offered at the home were good and ensured that the individual dietary needs of the residents were met. EVIDENCE: Daily activities and forthcoming events were displayed in the hallway. The acting manager said that the daily activities “could be flexible”. The summer Fayre and visiting artistes were advertised. Residents said, “there were no regular trips out”. The acting manager confirmed this and she said that there “were problems with transport” but she hoped to pursue it. The last “group outing” had been to visit a Pantomime at Christmas. The inspector asked how residents who were immobile saw what was on the activity board in the hallway. Staff said that they told residents what was going on. Residents spoke with confirmed this. For those residents unable to attend their own Churches, some residents told the inspector that visiting clergy or Church representatives visited on a regular basis. The Sacrament was offered every month. The acting manager was “considering quarterly residents meetings”. At the present time they were only held for special events and one was being considered for the Summer Fayre. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 14 Information relating to visitors and visiting was written in the Statement of Purpose and Service Users Guide. Staff said that there was “open visiting”. Some residents said that they went out with their families. One resident said that his son “visited daily”. Another said that a member of staff would take a couple of them out for a walk. No visitors were available to speak with during the day of the inspection. A tour of the home showed that some residents had brought their own personal items with them. Records showed that upon admission, a room audit was completed and signed by the resident concerned. It was recommended that a record be maintained of any furniture that residents brought into the home. The acting manager said that residents or their families controlled their own finances. Information relating to the East Lancashire Advocacy Service was displayed on the notice board. Records were maintained and stored appropriately. The breakfast and supper menus were displayed on the notice board in the hallway. The daily menu was displayed in the dining room and in the lounge. A hot main meal was served at lunchtime with an alternative available if required. The cook said that she would ask residents what they wished for an alternative if she knew that they did not like the meal available. A lighter type, hot meal or sandwiches was available at teatime. The cook kept a record of any snacks served to residents during the day. She said that specialised diets were available for two diabetics. Discussion between the cook and inspector resulted in a recommendation that blended meals should have each food blended separately in order to provide a meal with varied texture, colour and taste. The inspector joined the residents for lunch and observed that the residents were encouraged to be independent when eating. Staff were seen to offer any assistance needed in a calm and unhurried manner. Comments from residents in relation to the quality of meals ranged from “meals are good” to “meals are alright”. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 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 standard(s) 16;18 Some policies and procedures were available to protect residents from abuse although further “in house” procedures were required. The homes complaints procedure was incomplete. EVIDENCE: A copy of the complaints procedure was included in the homes Statement of Purpose. It contained most of the required information apart from any reference to the CSCI. The complaints book was kept in the entrance hall and had no further entries since the inspector last examined it. Residents and staff spoken with were aware of the procedure. Several residents informed the inspector that they knew who to talk to if they were not happy about things. There was a copy of the Blackburn with Darwen adult abuse procedure available. Two staff had been on the Protection of Vulnerable Adult course organised by the Local Authority. One staff member commented, “we are always learning”. Not all policies and procedures were in place, at Oldfield House, to safeguard service users from possible financial abuse. The home is part of a group of three homes. The required policies and procedures had been produced at one of the homes, but the acting manager was unaware whether Oldfield House had its own independent copies. Monies for two residents were maintained in the home. Two signatures were obtained for all transactions (resident and staff). The monies were kept securely. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 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 standard(s) 19;25;26 The home was warm, clean and comfortable. Equipment met the resident’s needs. A good standard of hygiene was achieved. Some “Water related” Regulations were not met. EVIDENCE: Ongoing maintenance throughout the home was noticeable. A record of routine maintenance was seen. The health and safety office carried out monthly safety checks and outcomes were seen to be recorded. The grounds were safe, tidy and accessible to residents. Fire equipment examined was maintained and regularly serviced. Staff spoken with were aware of the fire drill procedure. The Fire risk assessment relating to the home was awaiting review. The inspector conducted a tour of the building. A variety of aids were seen in various parts of the home. All windows had restrictors fitted which enabled residents rooms to be ventilated naturally and safely. Bedrooms were centrally heated and residents said that they were able to control the temperature if Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 17 they wished but “usually asked the staff”. Emergency lighting was provided throughout the home. Residents felt that the lighting was adequate for their needs. Thermostats were fitted onto water outlets. The inspector tested random outlets and temperatures were within the recommended range. Records examined showed that senior staff made daily checks on water outlet temperatures. The acting manager was unaware whether the requirement made at previous inspections in respect of the testing of stored water for the prevention of Legionella had been complied with. She told the inspector, “If I work out how it’s done, I’ll do it everyday!” Laundry facilities were sited away from any areas associated with food. The floor was impervious and the walls were easily washable. The washing machines reached temperatures above 65 degrees centigrade and met disinfection standards. Dryers were available. The home had a current clinical waste certificate and protective clothing was provided for staff. There was no sluice, but a sink was provided in areas where clinical waste was handled. Liquid soap and paper towels were provided in bathing areas and in the laundry. Policies and procedures were available for the control of infection. The acting manager was unsure whether services and facilities complied with the Water Supply (Water Fittings) Regulations 1999. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 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 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) 27;28;29;30 The numbers and skill mix of staff met residents’ needs. Staff were recruited using current guidelines but not all recruiting documentation was retained on staff files. Staff received training suitable to the residents residing at the home. EVIDENCE: The staff compliment remained at the level as agreed with the previous registration authority. The staff rota showed that additional staff were on duty if the dependency levels of residents required this. A cook was employed for 35 hours a week and a maintenance person was shared with other homes in the group. Care and domestic duties were combined. Records showed that 63 of the care staff had achieved NVQ level 2. In addition, some staff were due to complete their course during June 2005. Staff under the age of 18 years were not employed and the use of agency staff was avoided. The staff file of the acting manager and the newest member of staff were examined. Files contained application forms and although the acting manager said that references had been sent for, replies were not on the staff files. The acting manager said that these were retained at the Group office. There was evidence of CRB’s being applied for and there were responses confirming clear POVA checks. Staff indicated that they had received their own copy of the Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 19 General Social Care Council Code of Conduct and Terms and Conditions of Employment (Contract). Individual training records were viewed on a number of staff files. They showed that a variety of core training was offered. Staff said that they felt confident to meet the assessed needs of the residents and confirmed that they received the required days of paid leave for training purposes. The acting manager said that she thought that the induction and foundation training provided in the home met the current requirements, but she was not sure. A requirement was made in respect of this. Some staff had attended an accredited medication course. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 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 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) 31;33;35;36;38 Although the manager had resigned and an acting manager was in post and applying to be registered, the welfare of residents was sufficiently protected. The acting manager was developing a Quality Assurance process in order to gain valuable feedback in respect of developing the service provided. Some maintenance records were incomplete because not all documentation was retained in the home. This could result in the safety of residents being compromised. Staff received adequate supervision enabling them to provide suitable care for the residents. EVIDENCE: The acting manager had worked in the capacity of a Senior Carer within the Group for a number of years. She said that she was due to commence training in respect of the NVQ level 4 and the Registered Managers Award in September 2005. She had received a job description in her role as manager, which she felt, would assist her in fulfilling her new role. She was responsible Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 21 for one home only. Reference to the lines of accountability in the Statement of Purpose need to be updated, with reference to the previous manager, who resigned in March 2005, being removed. Residents spoke with were able to identify who the new manager was. Regulation 26 reports have been received on a spasmodic basis. The last two reports had been forwarded for January 2005 and February 2005. The manager of another home in the Group had completed these. The home had gained the Blackburn with Darwen Quality Assurance Award. The acting manager said that feedback from residents in respect of standards within the home was obtained verbally. She said that she intended to start her own information gathering and was to collate the information on an annual basis and insert the results into the Service Users Guide. The acting manager was not aware that some requirements and recommendations made during previous inspections had not been fully actioned. The acting manager kept the money of two service users securely. The inspector checked that staff administered the records and the money correctly. The acting manager said “relatives tended to oversee finances”. The receipt book showed that receipts were issued for valuables or monies held or given out. Staff spoken with said that they received the correct amount of supervision. Supervision records showed that supervision meetings were held on a monthly basis. The acting manager said that this was to be changed to once every two months. All areas of the requirements of supervision were covered. Records were seen of issues raised by the member of staff responsible for health and safety within the home. There was a copy of the document, “5 steps to Risk Assessment”. Many of the aspects of the health and safety training of staff was covered in the NVQ training. Staff spoken with were aware of their responsibilities. Records were maintained for accidents. Fire extinguishers examined had been serviced. but the homes fire risk assessment required reviewing. There was no evidence available in the home that stated that remedial work required, following the inspection of the fire system on 25.05.04, had been completed. The acting manager said that this information would be retained at the Group office. Various records were examined in respect of the maintenance of equipment throughout the home. There was no up to date copy of the maintenance of the “hard wired” electrical systems. Again, the acting manager said that this would be retained in the Group office. Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION 3 x x x x x 2 2 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 x 2 x 3 3 x 1 Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 23 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. Standard 9 Regulation 18 (1) (a)(c) Requirement The acting manager must undertake accredited training in the administration of medication. She must familiarise herself fully with policies and procedures relating to medication. The registered person must ensure that the complaints procedure (including that which is described in the Statement of Purpose) includes the name, address and telephone number of the C.S.C.I. The registered person must ensure policies and procedures be made available, at Oldfield House, to safeguard residents from possible financial abuse. (Timescale of 31.12.04 not met) The registered person must ensure that water is stored at a temperature sufficiently high enough to prevent Legionella. (Timescale of 31.12.04 not met) The registered person must ensure that all documentation relating to the recruitment of staff is maintained in the staff file and retained in the home. (Timescales of 31.12.04 and 31.12.03 not met) Timescale for action 30.09.05 2. 16 22 (7)(a) 31.07.05 3. 18 13 (6) 31.07.05 4. 25 13 (4) (a - c) 30.06.05 5. 29 17 (2) (a)(b) 30.06.05 Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 24 6. 30 18 (1) (a) (c) 7. 31 18 (1) (a) (c) 8. 31 26 (2)(3)(4) (5) 24 (1) (2) (3) 9. 33 10. 38 23 (4) The registered person must ensure that staff induction and foundation training meets the current requirements (N.T.O. sepcifications) (Previous recommendation) The registered person must ensure that the acting manager becomes suitable qualified, is competent and has the required experience to manage the home. The registered person must ensure that visits under this regulation are carreid out at least once a month. The registered person must ensure quality assurance systems are in place, as detailed within this standard. (Timescale of 31.03.05 not met) The registered person must ensure that the Fire Risk assessment is reviewed on an annual basis. (30.06.05 30.06.06 30.06.05 30.09.05 Immediate 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. 2. 3. 4. 5. Refer to Standard 3 14 15 26 38 Good Practice Recommendations Upon completion of the admission needs assessment, the member of staff and resident/relative should sign this confirming that they agree with any decisions taken. A record should be maintained of any furniture that the resident may bring into the home. Blended meals should have each food blended separately in order to provide a meal with varied texture, colour and taste. The registered person should ensure facilities and services comply with the Water Supply (Water Fittings) Regulations 1999. (Previously recommended) The registered person shoould ensure that up to date copies of maintenance certificates are retained at Oldfield House. F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 25 Oldfield House Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 1st Floor, Unit 4 Petre Road, Clayton-Le-Moors Accrington Lancashire. BB5 5JB 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 Oldfield House F57 F07 S5831 Oldfield House V225300 230505 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!