CARE HOMES FOR OLDER PEOPLE
Oldfield Manor Oldfield Manor 14 Hawkshaw Avenue Darwen Lancs BB3 1QZ Lead Inspector
Jennifer M Turner Unannounced Inspection 5th January 2006 10:00 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 Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 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) Oldfield Manor Limited Mrs Carol Ann Waddicor Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 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 7th and 10th June 2005 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 owned privately 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 ensuite 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. Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 5th January 2006 between 10am and 3.15pm. The Pharmacy inspector was also in attendance between 10am and 1.50pm and has produced the results of her inspection in a separate letter. Information was obtained by talking with the registered manager, staff members, a visiting professional, a student and 6 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 comment cards had been 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. At the time of the inspection the home had an occupancy level of 13 residents. A multi disciplinary strategy meeting had been held in November 2005 under the Protection of Vulnerable Adult Procedures. A satisfactory conclusion had been reached. What the service does well:
The assessment of residents prior to admission ensures that staff are able to meet the residents needs. Residents staying at the home for a period of respite care have their care plan updated upon arrival if they have stayed at the home previously. Care plans are reviewed monthly and some residents said that they were “included in their review”. Residents spoken with said that “the staff were kind and looked after them well”. They felt that their privacy was respected and commented that staff “knock on my bedroom door before entering”. The cook is able to provide a wholesome, balanced diet and provide any specialist meals. Residents commented generally “meals were good”. Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 6 Every three months, national minimum standard checks are completed with residents. This offers them the opportunity to make comments in respect of how their home is run. Protection of Vulnerable Adult Procedures are in place to protect residents. What has improved since the last inspection?
Residents are being encouraged to sign their care reviews. This ensures that they are fully aware of any decisions being made about their lifestyle. The daily menu is displayed in the dining room. This ensures that residents can request an alternative if they do wish to have what is being prepared. Refurbishment has taken place in some areas of the home ensuring that residents continue to live in pleasant surroundings. New carpet has been laid on the landing and stairs and in some bedrooms. Some new “self rising” chairs have been purchased. The Criminal Records Bureau/Protection of Vulnerable Adults process in relation to staff recruitment has improved. This ensures that as far as is able, residents are being protected from “undesirable staff”. The staff induction process has improved and the Common Induction Standards are now used. This enables staff to be offered a nationally recognised level of induction training. Staff continue to undertake NVQ training at level 2 and ongoing training was evidenced. This ensures that a well-trained workforce cares for residents. Staff said that they were offered training opportunities. Resident are being involved more fully in respect of quality assurance issues. This ensures that they are encouraged to make valued comments in respect of their home. A number of policies and procedures have been reviewed ensuring that current standards and legislation continue to be improved. Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 7 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. Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 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.V255840.R01.S.doc Version 5.0 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 the following standard(s): 3 A comprehensive assessment procedure was carried out prior to people moving into the home. This meant that their needs were known and met. EVIDENCE: Five case files were examined. Pre admission assessments were provided by social workers. The manager said that she “would normally visit prospective residents in their own home or in hospital”. Relatives were also encouraged to visit the home. 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. Assessments completed by the manager were seen on residents’ files. These covered all areas of this standard. A Falls Risk assessment and Nutritional assessment were also completed. The manager said that “a letter of suitability” was sent to prospective residents or their relatives, confirming that the home could meet their needs. Evidence of these letters was seen on case files. Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7;9;10 Residents’ healthcare needs were identified and met. EVIDENCE: Individual care plans identified the full range of resident’s care needs. The manager, key worker, residents and sometimes relatives were involved with the monthly reviews. Records showed that residents and their relatives were encouraged to sign these review sheets. Risk assessments, relating to the prevention of falls were seen on residents’ case files in addition to information produced by the National Osteoporosis Society. The Pharmacy Inspector inspected the medication practices and has completed a separate report. Through discussion, staff were able to explain how care practices ensured that residents privacy was preserved. A telephone was sited in the dining room but the manager said that there was provision for telephone calls to be made in private. Telephone sockets were seen in some bedrooms. The term of address as preferred by the resident was seen written on their care plan. Although there was one double room, all residents were accommodated in single occupancy rooms.
Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 11 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): 15 Meals offered at the home were good and ensured that the individual dietary needs of the residents were met. EVIDENCE: The record of meals served was shown to the inspector. In addition, a record was maintained of anything that residents asked for in between meals. The cook said that specialised diets were available. 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. Throughout the inspection, residents were seen to help themselves from jugs of juice that were available on a table in the lounge. Staff assisted those who could not manage themselves. Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 12 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 Procedures in place and the training given to staff ensured that residents were safeguarded. Amendments should be made to the complaints procedure so that residents can fully understand the correct procedure. EVIDENCE: There had been no complaints made to the Commission for Social Care Inspection since the last report although one complaint had been satisfactorily dealt with internally. Although it was recommended that the complaints procedure be rewritten in a format that was more “user friendly”, several residents informed the inspector that they knew who to talk to if they were not happy about things. A copy of the Blackburn with Darwen adult abuse procedure was available. Staff indicated that they were aware of the policy and of their role. Some staff had undertaken appropriate training. A policy and procedure was in place in the event that staff might face physical or verbal aggression from residents. There was also a policy available to guide staff when dealing with residents’ monies. A multi disciplinary strategy meeting held since the last inspection under the Protection of Vulnerable Adult Procedures had reached a satisfactory conclusion. Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 13 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 The home was warm, clean and comfortable. Equipment met the resident’s needs. A good standard of hygiene was achieved. EVIDENCE: By walking around the home, ongoing maintenance was noticeable and further plans were discussed with the handy person. A record of routine maintenance was seen. The health and safety officer carried out monthly safety checks and outcomes were recorded. The grounds were tidy and a ramp at the front door enabled residents to access the front of the home. There was a sunken garden area that was accessible to those residents who were more mobile. Fire equipment examined was maintained and regularly serviced. From discussion, staff were aware of the fire drill procedure. Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 14 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): 28;29;30 The numbers and skill mix of staff met residents’ needs. New staff were recruited using current guidelines but not all up to date documentation was available on staff files. Staff received training suitable to the residents residing at the home. EVIDENCE: Records showed that 33 of the care staff had achieved NVQ level 2. Some members of staff said they were awaiting confirmation of places. The registered person now advertises for staff who hold an N.V.Q. qualification. Three staff files were examined. Not all contained the appropriate information as laid down in Schedule 2. Criminal Record Bureau and Protection of Vulnerable Adult checks were carried out. There was evidence that staff signed documentation indicating that they had received a contract of employment. Staff members said that they had their own copy of the General Social Care Council Code of Conduct. A staff-training matrix was seen which 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 manager said that new staff completed the new Common Induction Standards prior to them commencing work, and were then enrolled for NVQ training.
Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 15 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 The welfare of residents was sufficiently protected. The manager was developing a Quality Assurance process in order to gain valuable feedback in respect of developing the service provided. Maintenance records were retained in the home. EVIDENCE: The manager holds the NVQ at level 4 and had almost completed the Registered Managers Award. She also holds the D32 and D33 awards. She has received a job description in her role as manager. She is responsible for one home only. Clear lines of accountability are shown in the Statement of Purpose and Service Users Guide. Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 16 An annual development plan was in place and the manager initialled jobs when they were completed. The home had gained the Blackburn with Darwen Quality Assurance Award. Every three months the manager said that she completes national minimum standard checks with the residents. Some residents said they remembered signing these. Regulation 26 reports had not been forwarded to the CSCI since July 2005. A further requirement was made regarding this. The manager kept the money of one resident securely. Although receipts were kept it was recommended that a book be used to record any transactions instead of on “bits of paper”. The manager said that in general “relatives tended to oversee finances”. Many of the basic aspects of the health and safety training of staff was covered in the NVQ training. Staff spoken with were aware of their responsibilities in respect of health and safety. They also said that they discussed their training requirements during staff supervision. An environmental risk assessment had been completed. Fire equipment examined had been serviced, and the homes fire risk assessment had been reviewed. Various records were examined in respect of the maintenance of equipment throughout the home. They were all up to date. Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 17 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 3 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 x 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 3 Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes All the requirements and recommendations listed below were identified during this inspection either by the Registration or Pharmacist Inspectors. The Pharmacist Inspector has made her comments in a separate letter. 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 OP9 Regulation 13 (2) Timescale for action Medicines must only be 31/01/06 administered to the resident for whom they were prescribed. There must be no sharing of creams or other preparations. Medication must not be “potted 31/01/06 up” in advance of administration. Medication must be administered to the resident directly from the original containers. The registered person must 31/03/06 ensure that all staff files contain all of the information as required in Schedule 2. The registered person must 31/03/06 ensure that visits under this regulation are carried out at least once a month. Previous timescale of 31.07.05 not met. Requirement 2 OP9 13 (2) 3 OP29 19 (4)(b) Sched. 2 24 (1)(2)(3) 4 OP33 Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 19 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 Refer to Standard OP9 OP9 Good Practice Recommendations Medication policies and procedures should be reviewed in line with the Royal Pharmaceutical Society of Great Britain guidelines to cover all aspects of medicine management. Criteria for the administration of “when required” and “variable dose” medication should be clearly defined and recorded for all residents prescribed such items. Verbal dose changes and new medication should be accurately entered onto the Medication Administration Record charts with staff signature, date and authority where appropriate. A second member of staff should witness all hand written annotations on Medication Administration Record charts. Residents’ blister packs should all be started on the same day. Keys to medication storage trolleys and cupboards should be on a separate key ring and only accessible to authorised staff. Medicines must be stored at the appropriate temperature. The opening date should be recorded on eye drops and other items with a short shelf life. A new Aerochamber should be obtained. Such devices must be kept clean and replaced regularly according to manufacturers instructions. 4 5 6 OP16 OP28 OP35 The complaints procedure should be written in wording that is easier for residents to understand. The registered person should continue to ensure that staff attain the relevant NVQ qualifications. A book should be introduced to record the income and expense of resident’s monies that are managed by staff at the home. 3 OP9 Oldfield Manor DS0000005832.V255840.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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