Inspection on 18/09/07 for Oldfield Manor

This inspection was carried out on 18th September 2007.

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 Manor 31/08/06

Oldfield Manor 05/01/06

Oldfield Manor 07/06/05

Oldfield Manor 07/12/04

Oldfield Manor 28/06/04

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 Manor Oldfield Manor 14 Hawkshaw Avenue Darwen Lancs BB3 1QZ Lead Inspector Jane Craig Unannounced Inspection 18th September 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oldfield Manor DS0000005832.V345186.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. Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oldfield Manor Address Oldfield Manor 14 Hawkshaw Avenue Darwen Lancs BB3 1QZ 01254 705650 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) K.Kumar985@btinternet.com Oldfield Manor Limited ***Post Vacant*** Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 31st August 2006 Date of last inspection Brief Description of the Service: Oldfield Manor is a converted two storey building set in its own grounds. There is car parking space at the front of the building. It is situated about 200 yards from the main Blackburn to Darwen main road, where there are a variety of shops and retail premises. This road is a bus route. The home is approximately one mile from Darwen town centre. Oldfield Manor is privately owned and is part of a small local group of three homes. Accommodation is provided on two floors. There are 15 single rooms and 1 double room. Some rooms have an en-suite facility (W.C. and wash hand basin). There is one lounge with a conservatory extension and a separate dining room. There are bathing and W.C. facilities on both floors of the home. A passenger lift connects the two floors. There is a sunken lawned garden at the front of the home which is accessed by steps. Access into the grounds from the home is via a ramp. A brochure about the home is sent to anyone enquiring about a place. Other information, including the latest CSCI inspection report is available to read during an initial visit to the home. The fees at 18th September 2007 were £354.00 per week. There were additional charges for personal newspapers, toiletries and hairdressing. People also paid for transport for non urgent hospital appointments. Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Oldfield Manor on 18th September 2007. There had been one additional visit to the home since the last key inspection. This random inspection, carried out on 6th March 2007, had been done to monitor progress towards meeting requirements made at the key inspection. At that time there had been little improvement. At the time of this visit there were 14 people living at the home. The inspector met with some of them and asked about their views and experiences of living at Oldfield Manor. Some of their comments are included in this report. Two people living at the home were case tracked. This meant that the inspector looked at their care plans and other records and talked to staff about their care needs. Before the inspection questionnaires had been sent out to nine people living at the home and to their family carers. Only one had been returned. Five healthcare professionals completed surveys. The majority of people’s views about various aspects of the home were positive. During the visit discussions were held with the acting manager, three other members of staff and a visitor. The inspector looked round the home and viewed a number of documents and records. This report also includes information from the Annual Quality Assurance Assessment (AQAA), which is a self-assessment that the manager has to fill in and send to the Commission every year. What the service does well: People said that staff gave them their privacy and treated them with respect. One person said, “they are never nowty and they always speak civilly.” Four of the healthcare professionals indicated that staff always respected people’s privacy and dignity. Staff made sure that people who were not well were referred to a doctor. Most of the health professionals who completed surveys indicated that people’s health care needs were usually met. There was open visiting which meant that people could see their visitors at any time. Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 6 People were satisfied with the meals, which some described as very nice. They said they could have something different if they did not like what was on the menu. People living in the home were able to make choices about some aspects of their daily lives. One person said, “I like to go to bed early and I get up when I want.” Another person said they liked to spend their time reading and got books from the library. Everyone was given a complaints procedure which meant that they knew how to make a formal complaint and how they could expect it to be dealt with. People using the service said they were able to speak to the staff if they had any complaints. People living at the home said they got on well with the staff. Their comments included: “the staff are very nice and they work very hard,” “all decent people,” and “the staff are wonderful, caring people who have the patience of Job.” One health professional wrote that staff were helpful and another made a comment that staff have good relationships with clients. What has improved since the last inspection? What they could do better: Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 7 There had been some improvements in the way staff managed people’s medicines. However, a number of recording, administration and safety issues needed further improvement to make sure that people received their medicines as they should. A number of people living at the home said there were not enough organised activities. One person described it as being “quite dead,” and another said, “We need someone to liven us up.” A healthcare professional also wrote that people using the service needed more stimulation. In order to prevent injury to people living and working at the home, there must be the right equipment to help people who are unable to stand up or move by themselves. Records must be kept of any accidents involving people living at the home. This would help staff to identify people who are at high risk of falling and put plans into place to help them. Staff were storing their belongings in bathrooms and a bedroom. This shows a lack of regard for people’s privacy and should stop. Fire safety training was not up to date and not all staff had participated in practice drills. This meant that people could not be sure that all staff knew how to react in the event of a fire. The manager was arranging training for later in the month. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process ensured that people were not admitted to the home unless their assessed needs could be met. EVIDENCE: People thinking of using the service had access to the statement of purpose and service user’s guide. People had copies of the terms and conditions of residency on their files. As recommended following the last inspection, the manager had drawn up a document to assist senior staff to assess people who were thinking of moving into the home. The manager talked about the importance of assessing people to ensure that their needs could be met and also that they would fit in well with the current residents. Standard 6 is not applicable, as Oldfield Manor does not provide intermediate care. Oldfield Manor DS0000005832.V345186.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls in care planning and delivery meant that not everyone’s health and personal care needs were met. EVIDENCE: The care records for two people were looked at as part of the case tracking process. Others were looked at in less detail. In most cases there were care plans in place to address people’s assessed needs. Some were highly personalised and gave staff precise directions about how individuals wanted to be supported. Others were brief and did not contain enough information specific to the person, which could result in inconsistent care. Care plans to meet people’s mental health needs were generally not precise enough. On the day of the visit, staff were not consistent when approaching a person who was disorientated and anxious, which could increase the person’s Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 11 confusion and agitation. A member of staff confirmed that the staff all had their own ways of dealing with people with confusion and no-one was sure which was correct. All the plans seen showed evidence that the person using the service, or their family, had seen and agreed them. Care plans were reviewed every month. Some of the reviews included outcome statements, which meant that staff could see whether their interventions were working. Other review notes were brief and uninformative. Care plans were not always updated when the person’s needs changed or staff had to provide different care. For example, the dietician had given advice to staff about fortifying food for a person who was losing weight. This information had not been incorporated into the care plan. As previously required, people had health care risk assessments on their files. However, these were not always accurate and up to date. For example, one person’s nutritional risk assessment had not been updated even though they were losing weight. Another person’s moving and handling assessment was not accurate because it did not take into account two high risk factors. There were not always strategies in place to manage risks to people’s health. For example, one risk assessment showed that the person was at risk of developing pressure sores but there was no plan to direct staff to use preventative measures. There were no accident reports for a person whose notes indicated that they had been found on the bedroom floor twice in a week. The lack of reporting may result in risk assessments not being changed and preventative measures not put into place. Staff were observed using an underarm lift on one person. They were aware this was not good practice and could cause injury to the person and themselves but there was no hoist in the home. The manager said that there was a stand aid on order. There was evidence that people were referred to healthcare professionals if needed. People spoken to at the time of the visit said that if they were poorly staff looked after them very well. Four of the five health professionals who completed surveys indicated that staff sought and acted upon medical advice and that people’s healthcare needs were usually met. The medication policies were under review at the time of the visit and were not looked at. Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 12 Some of the requirements made at the last inspection to improve the way medicines were handled had been addressed but there were still a number of shortfalls. Two people who administered some of their own medicines had not been assessed so staff could not be sure that they were safe to do so. Although there were no gaps on the Medication Administration Record (MAR) charts, some of the recording showed a lack of attention. For example, a member of staff had signed that they had administered night medication in the morning and another had signed that they had given medicine that was no longer prescribed but had not signed the one that they had administered. There were records of medicines received and returned to pharmacy. New medicines were received monthly. Staff kept records of medicines carried over from the previous month. However, these records were not always accurate which meant that there was no audit trail. Handwritten entries on MAR charts accurately reflected instructions on the medicine labels but none were signed and witnessed. This meant that errors in transcribing might not be identified. There was only one bottle of a type of liquid medication on the medicine trolley, which could indicate that medicines were still being shared. A number of people were prescribed “when required” medicines but there was no written criteria to alert staff when they should be given to people who were not able to request it. This could result in people being under or over medicated. Storage of medication was safe. Daily temperatures were recorded and maintained within acceptable limits. There were no excess stocks of medicines. Most staff had received training that covered core care values. They discussed how they upheld people’s rights to privacy and gave examples of ensuring doors were closed when they were giving assistance with personal care. Staff were observed speaking to people with respect and approaching sensitive subjects discreetly. People using the service said that staff were polite and respectful. One person said, “Staff are never nowty, they always speak to us civilly.” Oldfield Manor DS0000005832.V345186.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service were able to make choices about their daily their lives but not everyone’s social and recreational needs were met. EVIDENCE: There were mixed views about the level and range of social and recreational activities on offer. The activity programme on display indicated that there was an organised activity every morning and afternoon but this was not happening at the time of the visit. Seven people living at the home said that there was nothing much going on except a game of bingo sometimes in an evening and weekly exercises for a few people. One person said they were very bored, another said, “it’s quite dead,” and a third commented that there was, “no entertainment of any description.” Staff said they tried to get activities going if there were enough free staff to do so. The manager gave examples of activities that had been tried, including outside entertainers, but said the uptake by people living at the home was very poor. People said they were given choices in some aspects of their day. They said they could get up and go to bed when they wanted and spend time in their rooms if they wished. People still had set times for having a bath. Care plans Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 14 contained useful information about people’s likes, dislikes and preferences which helped staff to make choices for people who were not able to make decisions for themselves. Care plans also included information about people’s religious and spiritual needs and the manager had organised for people to receive Holy Communion on a regular basis. There was an open visiting policy and the visitor spoken with said he was made to feel welcome. The manager said people could stay for a meal if they wished. Some people went out with their families and the manager said there had been some trips out in to local places of interest. Information submitted in the Annual Quality Assurance Assessment (AQAA) indicated that the meals had been revised as a result of listening to what people living at the home wanted. There were no written menus and the manager said that the menus were decided on a weekly basis, with the cook going round asking for suggestions. People using the service were very positive about the food. Their comments included: “very well cooked,” “the food’s very good,” and one person said, “the food’s quite good, you can have a special meal if you want one.” Another person commented that they were able to have an alternative because they did not like fish. Records showed that people received a balanced diet. There was plenty of fresh fruit for people to help themselves. Oldfield Manor DS0000005832.V345186.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service were safeguarded by the complaints and protection procedures followed by staff. EVIDENCE: There was a clear complaints procedure on display and the manager said that everyone had been given a copy. People using the service said they would be able to go to staff if they were unhappy about anything and most of the healthcare professionals indicated that staff would address any concerns that were reported to them. There had been one complaint made directly to the home since the last key inspection. The manager had resolved the issue to the satisfaction of the complainant. Information submitted in the Annual Quality Assurance Assessment (AQAA) indicated that all staff had received training in safeguarding adults. There was also a clear policy and staff had the Blackburn with Darwen safeguarding procedure to refer to. Staff spoken with were aware of their responsibilities in reporting abuse and the manager was clear about her role should an allegation be reported to her. Oldfield Manor DS0000005832.V345186.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all areas of the home were hygienic, comfortable and well maintained. EVIDENCE: As required following the last inspection the manager had carried out audits on each bedroom to identify areas in need of redecoration and renewal. Two of the people who were case tracked had signed a document indicating that their rooms met their needs. A walk round the building showed that several bedrooms had been redecorated. Some also had new carpets and curtains. Several items of bedroom furniture had been replaced although none of the rooms seen had matching furniture. There were still a number of areas that needed redecorating. One person commented that the place could do with, “shaping up.” There was an action Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 17 plan with timescales to address most of the shortfalls. The manager also said a grant had been obtained to refurbish the downstairs bathroom and shower room. The garden to the front of the home was well maintained. However, there were piles of rubbish and paint cans in the rear yard area. This provided a very unattractive view for people whose rooms looked onto the yard. There was a shortage of storage space and staff coats and bags were still being kept in bathrooms and in a bedroom. A wheelchair, not belonging to the occupant, was also being stored in a bedroom. Most areas of the home were clean and tidy at the time of the visit and there were no unpleasant odours. However, the vinyl on the dining room floor had crevices that were full of food debris. As well as looking unpleasant this could act as a reservoir for bacteria. The manager said that most staff had received infection control training. A member of staff who had not yet had any formal training said that she had been told to use gloves and aprons when assisting with personal care. Staff did not have access to the most recent guidance on infection control, which the manager said she would try to obtain. The laundry was sited in the basement. There had been one complaint about clothing being spoiled and at the time of the visit care staff were washing some clothes by hand because the washing machine could not cope with delicate fabrics. The manager said that there was a second machine on order, which would address this problem. Oldfield Manor DS0000005832.V345186.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment practices provided safeguards for people living at the home and improvements in training meant that staff had a better understanding of how to meet people’s needs. However, staffing levels did not always meet people’s needs. EVIDENCE: Four of the people living at the home said that there were not always enough staff. One said that a shortage of staff meant they did not always get their game of bingo. Another person said, “many times there are only two staff which makes it difficult especially if people want to go to the toilet at the same time.” The manager and staff did not believe that this accurately reflected the situation. One said that they sometimes struggled during holiday periods but the manager always got someone. The manager confirmed that this was the case. Inspection of the duty roster showed that there were only two staff on some of the afternoon shifts. The rosters were not altered when there were any changes and did not provide an accurate record of which staff were on duty at any given time. Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 19 Some people using the service also commented that there was a high turnover of staff but this was found not to be the case. The manager said that they could have mistaken agency staff for new employees. All of the people spoken with praised the staff. One person said, “the ladies that look after you are very nice.” Another commented, “ The staff are wonderful, caring people who have the patience of Job.” Recruitment practices had improved. The files of three recently appointed staff were inspected. With the exception of one reference, all pre-employment checks had been carried out and the required documents and information were on file. There were records of staff supervision on the files seen and a member of staff said that she had had a one to one meeting with the manager, which she found useful. New staff had records of induction training on their files. The training programme met the Skills for Care common induction standards and included an assessment of competency on completion. The training records were signed by the manager but not the member of staff. Other training opportunities had improved. Although the training records were not inspected, the manager said that most staff had received training in the safe working practice topics. Several members of staff had also received training in other topics relevant to older people. There had been no dementia care training but the manager said this was planned for next month. 50 of staff were trained to NVQ level 2 or above. Oldfield Manor DS0000005832.V345186.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements were being made to ensure the home was run in the best interests of the people living there but some shortfalls in health and safety practices could place people at risk of harm. EVIDENCE: A new manager had been appointed in May. She held an NVQ 4 in care and management and had experience in managing a care service. The manager was not yet registered with the Commission for Social Care Inspection, although she said that an application was being processed. Although she had started to work towards improving standards, the manager was aware that there were still a number of areas that needed improvement. The manager of another home in the group supported her. Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 21 The manager had carried out a general audit shortly after taking up post. Questionnaires had been sent out to people living at the home, their families and other stakeholders, such as health care professionals. An action plan had been drawn up to address any shortfalls identified and suggestions for improvements had been accommodated where possible. For example, the questionnaires asked people whether their religious and cultural needs were met. In response to suggestions the manager had arranged for people to receive Holy Communion in the home. The manager intended to do a follow up audit in the next few weeks. The service had regained the Blackburn with Darwen Quality Assurance Award. The manager said that money and valuables were no longer held on behalf of people using the service. She said most people managed their own personal allowance and paid hairdressing bills themselves. Others were paid out of petty cash and their families were invoiced. Despite a previous requirement staff had not received fire safety training. The manager said it was booked for later in the month. There were monthly fire drills but not all staff had been involved. The fire procedure was not specific to the home but staff who were asked were able to describe their role in the event of a fire. Fire safety equipment was serviced regularly. Other equipment and appliances were serviced and maintained. The cleaning materials were stored in an unlocked cupboard on the corridor. There was no evidence that this had been risk assessed to ensure that this practice was not likely to cause harm to anyone living at the home who may not be able to recognise that they were hazardous substances. Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 23 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. Standard OP7 Regulation 15(1)(2) Requirement Care plans must provide up to date directions in enough detail that staff can be sure they are providing appropriate care in a consistent way. To protect the health and safety of the person and of staff, anyone with moving and handling needs must be assessed and the appropriate equipment and aids must be used to transfer them. Timescale for action 31/10/07 2. OP8 13(5) 30/09/07 3. OP8 4. OP9 17(2)Sche The registered person must keep dules 3 a record of any accident and 4 involving a service user. (Timescale of 31/03/07 not met) 13 (2) Medicines must only be administered to the person for whom they were prescribed. There must be no sharing of creams or other preparations. (Timescale of 31/01/06 not met) 23(4) In order to protect the people living and working at the home all staff must receive fire safety training and are involved in DS0000005832.V345186.R01.S.doc 30/09/07 30/09/07 5. OP38 30/09/07 Oldfield Manor Version 5.2 Page 24 practice drills. (Timescale of 31/12/06 not met) 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. Refer to Standard OP8 OP8 OP9 Good Practice Recommendations Health care risk assessments should be accurate and plans drawn up to minimise any risk. Accidents should be reported on to ensure that the correct preventative measures can be taken. Criteria for the administration of when required and variable dose medication should be clearly defined and recorded. This is to ensure that people receive the dose that they need when they need it. All handwritten entries on MAR charts should be signed and checked to ensure that instructions are recorded accurately. People should be assessed as to their ability and safety to administer their own medication. The programme of activities should be revised after consulting with people using the service about how they would like their social and recreational needs to be met. Staff belongings should not be stored in areas used by people living at the home. In addition to showing a lack of regard for people, it could also increase the risk of spread of infection. Staff should have access to up to date infection control guidance. The storage of cleaning materials should be risk assessed to ensure that the open storage does not pose a risk to people living at the home. 4. OP9 5. 6. OP9 OP12 7. OP19 8. 9. OP26 OP38 Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oldfield Manor DS0000005832.V345186.R01.S.doc Version 5.2 Page 26 - 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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