Inspection on 07/06/05 for Oldfield Manor

This inspection was carried out on 7th June 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 Manor 18/09/07

Oldfield Manor 31/08/06

Oldfield Manor 05/01/06

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 14 Hawkshaw Avenue Darwen Lancashire BB3 1QZ Lead Inspector Jennifer Turner Unannounced 07 and 10 June 2005 10:00 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. F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Oldfield Manor Address 14 Hawkshaw Road Darwen Lancashire BB3 1QZ 01254 705650 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 Carol Ann Waddicor Care Home Only Personal Care 17 Category(ies) of Old age, not falling within any other category registration, with number (OP) 17 of places F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 This home should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 07 December 2004 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. It is registered to provide personal care in a residential setting for 17 residents in the category of older people. 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. Various adaptations to promote independence and assist mobility are located around the home. At the time of the inspection there was an occupancy of 15 residents. F57 F07 S5832 Oldfield Manor V225369 070605 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 7th June 2005. A further visit was made on 10th June with a member of Lancashire Fire and Rescue Service in order to address some fire safety issues that had been identified on 7th June 2005. Information was obtained by talking with the registered manager, 3 staff members, 3 visiting professionals, 1 volunteer from a recognised voluntary organisation, 3 relatives and 13 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. One relative comment card was 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. On 17.05.05 the Commission for Social Care Inspection received a complaint concerning staffing levels, meals, lack of moving and handling equipment and the quality of plastic gloves and lack of plastic pinnies. Areas around staffing levels were upheld and an Immediate Requirement notice was issued to increase the staffing levels. The registered person responded to this immediately and staffing levels were increased to meet the dependency levels of the residents. Areas around meals and provision of protective clothing were not upheld and the issue of moving and handling equipment was unresolved. The registered manager has since dealt this with further. On 10th June an Immediate Requirement Notice was issued relating to a bolt type lock on the front door and alternative methods to be found instead of wedging “fire doors” open. The registered person has dealt with all the areas raised. 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. Resident’s healthcare needs were identified and met. F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 6 Residents were able to make choices so that their lifestyle met their preferences. Residents welcomed visits from a member of the “Pets As Therapy” organisation. Residents said that they enjoyed the company of the visiting cat. Meals offered at the home were good and ensured that the individual dietary needs of the residents were met. Equipment provided in the home assisted in the promotion of residents being independent. Upon admission, new residents were encouraged to bring personal items into Oldfield Manor. This made them feel more comfortable in their new surroundings. Residents retained their own G.P. upon admission to the home, and were not expected to change to the practice of the registered responsible individual. The grounds were accessible and tidy and provided pleasant surroundings for the residents in warm weather. What has improved since the last inspection? A number of procedures relating to the administration of medication have been reviewed. This ensures safe medicine practices. Records are kept of items that a resident brings with them into the home. This prevents misunderstanding between staff and relatives at a later date. Room audits showed what items of furniture are required by the National Minimum Standards for Older People and what the resident agrees to have in their room. Hand washing facilities have been provided in the laundry. This minimises the risk of cross infection. Staffing levels have been increased to meet the dependency levels of residents. This ensures that staff have enough time to deliver the required level of care to residents. This gives the manager more time to carry out managerial duties. A training matrix has been produced which shows the amount of training staff have undertaken. This ensures that qualifications and required training are kept up to date and that staff have the required knowledge to assist them in their work. F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 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. F57 F07 S5832 Oldfield Manor V225369 070605 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 F57 F07 S5832 Oldfield Manor V225369 070605 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. EVIDENCE: Three case files were examined. One was for the most recent admission into the home. Pre admission assessments were provided by social workers, either from the local area or the hospital. The manager said that she “would normally visit prospective residents in their own home or in hospital”. If this was not possible, because of distance, relatives were 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. F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 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 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. The manager, key worker, residents and sometimes relatives were involved, with the monthly reviews. The key worker signed the documentation. A recommendation was made that the resident be encouraged to sign (or make their mark) to indicate that they had been involved with the decisions made. If residents were not able to sign, a reference was to be made of this. Relatives were able to sign the review if they had been present. Risk assessments, relating to the prevention of falls were seen on residents’ case files in addition to information produced by the National Osteoporosis Society. Some residents told the inspector that they were “included in their review”. Changes in care were reflected in the reviews. The manager said that information relating to preferences concerning “death and dying” was “usually sought from relatives”. This information was seen recorded appropriately on the residents’ files. F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 11 Care plans showed that residents’ accessed specialist services. Opticians, dentists and the chiropodist all visited the home. Residents said they were able to visit the practices themselves if they wished. Hearing Aids were checked at the Audiology Department at Blackburn Royal Infirmary or the local Health centre. The District Nurse 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. Bathing and lifting equipment, pressure mattresses and pressure cushions were seen. Nutritional screening was carried out and records showed that this was reviewed on a monthly basis. Records showed that residents were weighed periodically. Residents usually retained their own G.P’s following admission. None of them were “patients” of the registered responsible individual. Policies and procedures relating to medication review remained outstanding from the previous inspection. The manager was obtaining all the patient information leaflets from the pharmacist before reviewing the procedures. This remains a requirement with an extended time limit to 31.08.05. Records showed that a risk assessment had been completed in respect of the resident who wished to administer their own medication. This was reviewed on a monthly basis as part of the care plan review. Records showed that staff recorded medication when it was received into the home. Medication waiting to be returned to the pharmacist was not locked away until it was returned. There was evidence that all staff authorised to administer medication had received the training from the Pharmacist at the local health centre. Only authorised staff had access to the “medicines key”. There was evidence in the drugs book that the temperature of the medication storage areas was recorded daily. A copy of the British National Formulary is still needed. The Controlled Drugs and the administration records and medication of three residents were checked and found to be correct. When the inspector arrived at the home, a resident was having his ears syringed, by a District Nurse, in the dining room. This was inappropriate in respect of the place and the privacy aspect. Although the resident had been asked about doing this in the dining room, it is the responsibility of staff to promote and protect privacy and dignity. The District Nurse said that “space was scarce” and they “have to have their files set out in the dining room when they visit”. The residents spoken with said that the staff were kind and looked after them well. They said that they “knock on my bedroom door before entering”. Staff said that they ensured that toilet and bathroom doors were closed when they attended to residents. 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. Although staff used the term of address as preferred by the resident, this preferred form of address was not always highlighted in the care plan. The manager said that she used another name for one resident as she had “heard his daughter call him that”. Although there was one double room, all residents were accommodated in single occupancy rooms. F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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 on the lounge doorway and in the main hallway. The manager said that residents were reminded on a daily basis about the activity available that day. During the inspection the inspector joined a joint resident and relatives meeting. A range of topics was discussed and the residents were encouraged to offer comments and suggestions. When asked about whether staff should arrange a party to commemorate the end of the war, mixed comments such as “I would come“ to “I’ve never been keen on parties” were raised. A written record was made of the meeting. The manager said “I will speak to people separately who are not at the meeting”. 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. Information relating to visitors and visiting was written in the Statement of Purpose and Service Users Guide. Staff said that there was “open visiting”. Visitors who were visiting at the time confirmed this. Some residents said that F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 13 they went out with their families. Another said that a member of staff would take some of them out for a walk. During the inspection there was a visitor from the “Pets As Therapy” organisation who had brought one of her cats to the home. The residents responded well to the attention from the cat and some residents commented about how it reminded them of when they had had their own pets. A tour of the home showed that some residents had brought their own personal items with them. Records showed that items of furniture or valuables brought into the home at the time of admission were recorded. The manager said that relatives collected residents pensions. Information relating to the East Lancashire Advocacy Service was displayed on the lounge door. Records were maintained and stored appropriately. The breakfast and supper menus were displayed on the kitchen door. Although there was a chalkboard in the dining room this was not used and residents said that they “didn’t know what they were having at meal times”. It was recommended to the recently employed cook, for meals to be written onto this board to enable residents to be aware of what was on offer at mealtimes. A record of meals served at lunchtime and at teatime was shown to the inspector. There was also a record maintained of anything that residents asked for in between meals. A hot main meal was served at lunchtime with an alternative available if required. A lighter type, hot meal or sandwiches was available at teatime. The cook said that a specialised diet was available for a diabetic. 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. Residents commented generally “meals were good”. 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. F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 14 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 required amendment. EVIDENCE: Although a copy of the complaints procedure was included in the homes Statement of Purpose and Service Users Guide, it was more a policy that a procedure. It did not outline clearly the steps to be taken by a resident if they felt that they had need to make a complaint or what to do if they felt that their complaint had not been resolved. A differently worded procedure was available for residents but although time limits were included, it was not a clear 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. Not all policies and procedures were in place, at Oldfield Manor, 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 manager was said that Oldfield Manor still required a copy of the policy and practice to be followed regarding the monies retained for one resident. This remains a recommendation. “Whistle blowing” and “Acceptance of Gifts” policies were made available. F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 15 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;24;26. The home was warm, clean and comfortable. Equipment met the resident’s needs. A good standard of hygiene was achieved. EVIDENCE: Ongoing maintenance throughout the home was noticeable. A record of routine maintenance was seen. Staff said that they noted any items requiring repair in the maintenance book and the maintenance person signed it off when completed. The health and safety officer carried out monthly safety checks and outcomes were seen to be 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. Staff spoken with were aware of the fire drill procedure. The inspector conducted a tour of the building. A variety of aids were seen in various parts of the home. Room audits were completed for each bedroom and there was evidence that residents signed these to confirm their agreement with the contents of the room. There was space on the form to record any items that the resident did not wish to have in their room. Door locks were F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 16 fitted onto all bedrooms but some residents said that they chose not to use them. All bedrooms had single occupancy and all bedrooms, apart from one were fully carpeted. Although laundry facilities were sited away from any areas associated with food, soiled laundry was carried through the top end of the dining room in black bags when there were no residents in the dining area. The laundry floor was impervious and the walls were easily washable. The washing machines met the required specification. 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 with liquid anti bacterial soap with paper towels being available. Policies and procedures were in place for the control of infection. F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 17 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. In general, 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: The staff compliment has been increased to meet the dependency levels of the present residents. A cook and domestic staff were also employed. A maintenance person was “shared” with other homes in the group. Records showed that 25 of the care staff had achieved NVQ level 2. This decrease had been caused by staff who held the qualification leaving the home. Two staff were due to complete their course during June 2005. Further members of staff were awaiting confirmation of places. The registered person now advertises for staff who hold an N.V.Q. qualification. Staff under the age of 18 years were not employed and the use of agency staff was avoided. Three staff files were examined. The file of the newest member of staff was included. Files contained application forms, references and Criminal Record Bureau information. There was evidence that one member of staff had brought her CRB, which was 2 months old, from another care home. It was explained to the registered manager that CRB’s were not portable and staff had to complete a new CRB application in order for a POVA check to be obtained. It was stressed that staff were unable to commence employment until a clear F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 18 POVA check had been received. The newest member of staff said that she had not received a job description or a contract of employment. Staff members indicated that they did not have 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 a general induction, usually two days prior to them commencing work, and were then enrolled for NVQ training. She did say that the induction did not meet the current National Training Organisation specifications. A requirement was made in respect of this. F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 19 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;37;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 2 and has almost completed her level 4 training. She said that she intends to complete 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. Regulation 26 reports have been received on a spasmodic basis. The last three reports had been forwarded for January 2005, February 2005 and May 2005. The manager of another home in the Group had completed these. F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 20 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. The manager said that feedback from residents in respect of standards within the home was obtained verbally. The inspector discussed with the manager the need to collate information obtained from residents annually and to insert the information gained in the Service Users Guide. During the residents meeting the staff talked about introducing a suggestion box to enable residents to make anonymous suggestions about the way the home was run if they wished. When asked about whether staff should arrange a party to commemorate the end of the war, mixed comments such as “I would come“ to “I’ve never been keen on parties” were raised. The manager said that she intended holding these meetings on a monthly basis. The manager kept the money of one resident securely. Although receipts were kept it was recommended that a record was maintained of income and expenditure with two signatures being obtained for all financial transactions. The acting manager said “relatives tended to oversee finances”. The manager said that residents could access their own records if they wished but during conversation none of the residents indicated a wish to do this. Residents’ records seen were secure and up to date. 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. A recommendation was made for the training matrix to show when certificates were due for renewal. Records were maintained for accidents. An environmental risk assessment had been completed. Fire extinguishers examined had been serviced, but the homes fire risk assessment required reviewing. An immediate requirement notice was issued in respect of alternative ways of wedging “fire doors” open. The registered person has addressed this matter since the inspection. Various records were examined in respect of the maintenance of equipment throughout the home. They were all up to date. F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 21 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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 2 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 2 x 3 2 F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 22 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 13 (2) Requirement The responsible person must ensure that policies and procedures for all aspects of medicines management within the home are reviewed in line with current Pharmaceutical Society of Great ritain guidelines. (Previous timescale of 28.02.05 not met) The registered person must ensure that all new care staff receive a current Criminal Record Bureau check and a POVA check. 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 Timescale for action 31.08.05 2. 29 19 (4) (b) Schedule 2 (7) 18 (1) (a) (c) Immediate 3. 30 15.07.05 4. 31 18 (1) (a) (c) 31.12.05 5. 31 26 (2)(3)(4) (5) 24 (1) (2) (3) 31.07.05 6. 33 30.09.05 Page 23 F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 systems are in place, as detailed within this standard. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 7 Good Practice Recommendations Residents should be encouraged to sign (or make their mark) to indicate that they have been involved with any decisions made during the monthly care review. If residents are not able to sign, a reference should be made of this. All out of date or disused medicine should be locked away until returned to the pharmacist. A copy of the current British National Formulary should be obtained as a reference source. Residents preferred name should appear in their care plan. The daily menu should be written on the chalk board in the dining room to enable residents to see what they are having at meal times. The registered person should ensure that the complaints procedure is written in a format that can be easily understood by residents. Although the time requirements were included, the steps to be taken by a resident if they felt that they had need to make a complaint or what to do if they felt that their complaint had not been resolved need to be clearly outlined. The registered person should ensure that copies of policies and practices, relating to residents finances maintained by the home, are available. The registered person should continue to ensure that staff attain the relevant NVQ qualifications. The registered person should ensure that each member of staff has their own copy of the Genreal Social Care Council Code of Conduct. The registered person should keep a record of income and expense for all financial transactions carried out on a residents behalf. The registered person should ensure that the training matrix shows when certificates are due for renewal. The registered person should ensure that the fire risk assessment is reviewed. F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 24 2. 3. 4. 5. 6. 9 9 10 15 16 7. 8. 9. 10. 11. 12. 18 28 29 35 38 38 F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 Page 25 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 F57 F07 S5832 Oldfield Manor V225369 070605 Stage 4.doc Version 1.30 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. 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