Inspection on 09/11/05 for Osborn Manor

This inspection was carried out on 9th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Osborn Manor 17/08/06

Osborn Manor 29/04/05

Osborn Manor 09/12/04

Osborn Manor 05/05/04

Osborn Manor 22/05/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Osborn Manor 38 Osborn Road Fareham Hampshire PO16 7DS Lead Inspector Annie Billings Unannounced Inspection 9th November 2005 11:00 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 Osborn Manor DS0000011768.V263905.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. Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Osborn Manor Address 38 Osborn Road Fareham Hampshire PO16 7DS 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) 01329 823216 osboenmanor@tiscali.co.uk Mr J Allen Mrs Jean-Anne Allen, Ms M Josephs, Mr D Smith Mrs Jean-Anne Allen Care Home 14 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (14), Old age, not falling within any other of places category (14) Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person under 55 years of age to be admitted in DE category A maximum of 2 service users may be accommodated in the DE category 29th May 2005 Date of last inspection Brief Description of the Service: Osborn Manor is situated on the outskirts of Fareham town centre, opposite Fernham Hall. The home benefits from being on a main bus route, and is directly opposite a variety of shops, library and a local medical practice. Set in immaculately kept grounds of nearly three quarters of an acre, the home is well screened from the road, and provides accommodation over three floors, within single and double rooms. Communal areas are well maintained, homely and comfortable, and provide a large, comfortable sitting room, a conservatory providing views over the gardens, a dining room and kitchen. Osborn Manor is registered to provide accommodation to fourteen older people, including those with dementia. Two residents may be admitted with dementia over the age of 55. Osborn Manor DS0000011768.V263905.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 over 5.5 hours and was the second inspection of the year April 2005 to March 2006. Many of the core standards were inspected during the previous visit on the 29th April 2005; therefore referral to both reports will give a full overview of the service. A partial tour of the premises took place and observation of daily routines within the home. Records were sampled and discussions were held with eight residents, one visitor and three staff members. Comment cards were also received from eight relatives and eight service users. Additional information was supplied within a pre-inspection questionnaire. An anonymous complaint was made to the commission regarding management arrangements following a recent flood, the quality of food, and accessibility of bathrooms for one resident. This was investigated as part of the inspection process, and these are referred to under the relevant standards in the report. The damaged areas were inspected and residents affected were spoken with. What the service does well: What has improved since the last inspection? Since the last inspection a new walk in shower has been installed to replace an old bath, locks have been fitted to the boiler room door to prevent residents burning themselves on uncovered hot water pipes and restrictors have been fitted to first floor windows, to prevent residents from falling. Action has been taken in respect of two issues identified at the last inspection, to minimise risk to residents. Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 6 Some decoration has taken place following a recent flood, although the skylight needs to be repaired before decoration can be completed. New activities are being introduced, to ensure that residents are provided with suitable stimulation. The manager reported that these have received a mixed response. Arrangements have been made for grab rails to be fitted to an exterior ramp and repairs to the car park, as this has been identified as a safety issue for residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected. EVIDENCE: Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 9 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): 9 Procedures for handling of medication are appropriate for the protection of residents, and meeting their medication needs. EVIDENCE: None of the current residents are self-medicating. The home operates a monitored dosage system for the administration of medication, in line with the home’s policy and procedure. The local pharmacist supplying the home audits stocks and records on a regular basis, and provides staff training in the safe handling of medication. The last audit report dated the 20th June was sampled. No issues were identified and one recommendation to provide a separate recording sheet for controlled drugs was made. There are currently no controlled drugs prescribed to residents. Stocks and records were sampled and found to be accurate. One signature omission was identified for medication administered to one resident on the 8th November. The manager agreed to follow this up with the member of staff. One resident confirmed that medication is always checked and given promptly. Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 10 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 Residents receive a balanced and varied diet, based on residents’ preferences. EVIDENCE: A four-week rotational menu is available, which has been developed from preferences of residents, as detailed within their files. Meals are varied and provide a roast meal twice a week. The main course does not offer a choice, but residents spoken with confirmed they could have an alternative if they requested it. Records sampled confirmed this. The lunch observed had been cooked by a member of the care staff, and was served hot, and attractively presented. One aspect of a recent anonymous complaint alleged that food is inedible. One resident spoken with said that the quality of food had improved, following the return of a member of staff, while other residents said they liked the food, and they didn’t have any problem. Of the comment cards received, seven residents said they liked the food, and one states, “not as much as before”. This aspect of the complaint has not been upheld. Lunch was served in the attractively furnished dining room, and staff were observed providing appropriate support where necessary. Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 11 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 A satisfactory complaints procedure is available, and people feel able to use it. EVIDENCE: A satisfactory complaints procedure is available in the home, which relatives and residents said they had been made aware of, and knew who to speak to if they were not happy with the service. No complaints have been received directly by the home, although one anonymous complaint was received by the Commission. Aspects of the complaint were in connection with the management arrangements following a recent flood, the quality of food, and accessibility of bathrooms for one resident. This was investigated as part of the inspection process, and the findings are referred to under the relevant standards in the report. The damaged areas were inspected and residents affected were spoken with. Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 12 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 is clean and provides a comfortable and friendly environment, but the safety of staff and residents is compromised by a number of health and safety issues. EVIDENCE: The commission were advised by the registered manager of several areas of the home suffering water damage following a flood on the 19th August, caused by a particularly heavy thunderstorm. A skylight at the top of the house was damaged, and drains were unable to cope with the volume of water, causing flooding in the lower ground floor affecting the office, one bedroom and private accommodation. The resulting damage affected walls and ceiling around stairwells on all levels, ceilings in two first floor bedrooms and hallway. One aspect of a recent anonymous complaint alleged that one resident remained in their flooded bedroom for 2-3 days, with sewage under the carpet. The complainant further alleges that the resident is unable to manage stairs to the bathroom, and has to access the bathroom via the garden and front door. Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 13 All affected areas were treated and sanitised by flood restoration specialists on the same day and dryers and dehumidifiers were used to dry out the areas. All affected floor coverings were removed, electrical installations, fire alarm, emergency lights and smoke detectors were checked and repairs made where necessary. Several areas have been redecorated, and plans are in place to complete redecoration following repairs to the skylight. New carpets are to be fitted on the 11th November. One of the residents occupying one of the rooms affected on the first floor said they were not even aware of the flooding, and had not been affected by the damage to the ceiling. A discussion was held with the resident affected in the lower ground floor room, who said they felt the home had managed the flood well. The area of carpeting closest to the door had been damaged. They confirmed they had been moved out of the room immediately, and moved in with friends while the room was completely refurbished, returning to the home for meals. Having moved back into the room on the 19th September, they said they were very happy to be back and had chosen the colour of decoration and carpet, which now looked lovely. The stairs between the ground and lower ground floor are quite steep, and damaged, loose underlay had been left on the stairs. This posed a potential trip hazard to staff and residents, and was removed on request during the inspection. Both residents on the lower ground floor said the steep stairs were not a problem and they managed quite well, although felt they would benefit from an additional handrail. This was discussed with the manager, who agreed to refer the premises for an occupational therapist assessment. One of these residents has an en-suite bathroom with shower, and the other an en-suite WC and basin. They said they were quite happy accessing the bathroom upstairs. One resident said they consider themselves very lucky to be in this room, and did not wish to move. This aspect of the complaint has not been upheld. No risk assessments were available for either resident in respect of these stairs, and this has been dealt with in standard 38. Another resident, partially sighted, was observed choosing to descend stairs unaccompanied, rather than use the stair lift. No risk assessment had been undertaken. Other environmental issues were identified that could pose risks to staff and residents: Several tubs of cream were found in the bathroom cabinet, one prescribed for a previous resident, and were removed immediately by the manager. The bath seat had been removed from the bath and placed on the floor. This was discussed with the manager, as being heavy could pose serious risk to staff lifting this equipment in and out, and was not in line with the home’s moving and handling policy. The manager agreed to risk assess Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 14 this practice and discuss this issue with the occupational therapist, as alternative equipment may be required to meet residents needs. Cleaning products were found stored in the unlocked larder cupboard, alongside food. The manager agreed to remove these immediately and place in a locked cupboard, as these can be potentially hazardous to residents. The flooring on the threshold of a first floor WC was loose and was a trip hazard. The manager agreed to address this immediately. Since the last inspection, a new walk in shower has been fitted, to replace an old bath, a lock has been placed on the boiler room door and restrictors fitted to first floor windows to prevent accidents. The premises itself is homely in appearance, and communal areas are well decorated and comfortably furnished. All areas were clean. Two chairs on the first floor landing looked tired and worn. The manager advised these will be replaced or recovered. The laundry facility is sited on the lower ground floor and is in need of repainting. Uncovered hot water pipes were identified, but no risk assessment is in place. The manager agreed to replace a badly stained mat and to consider fitting a light to the interconnecting area to ensure staff safety. The grounds to the property are generally well maintained, although a number of potholes have appeared in the car park. The manager advised that arrangements have been made to repair the surface, and to fit a handrail to the exterior ramp. The manager also agreed to ensure that moss is removed from the fire escape steps. Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 15 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): 29 Recruitment practices are robust, ensuring the protection of vulnerable people. EVIDENCE: Three staff files sampled confirmed that appropriate checks are undertaken prior to offering employment in the home. Files each contained evidence that two references had been undertaken, medical and criminal records bureau checks, proof of identity, interview notes, application form and induction training programme. Two files did not contain a photograph of the member of staff, although the manager confirmed these were underway. Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 16 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): 35, 38 Procedures in the home for safeguarding residents’ financial interests are good, but deficiencies in the management of risk do not promote the health, safety and welfare of staff or residents. EVIDENCE: Although quality assurance was not inspected on this occasion, three residents advised they would welcome implementation of formal residents’ meetings. The manager advised that informal discussion does take place, but indicated an intention to introduce formal meetings in future, to demonstrate residents’ involvement in the running of the home. All resident’s finances are supported by their families or advocates. Three records of personal allowances held by the home for safekeeping were checked, and found to be accurate and well maintained. Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 17 Accidents are appropriately recorded and the fire logbook evidenced that tests, checks and training takes place at the required intervals. Maintenance certificates are in place for all equipment in the home. There is currently no system to audit health and safety in the home. A number of issues were identified during a tour of the premises that could put staff and residents at potential risk e.g. steep stairs, cleaning substances hazardous to health not locked away, moving and handling practice, trip hazards. A number of risk assessments were available, but had not been reviewed since 2002. Other areas have not been risk assessed to ensure safe working practice or that the home remains hazard free. A letter has been sent to the providers to ensure that a health and safety risk assessment strategy is developed, with referral to an occupational therapist where necessary, to ensure that the home remains hazard free and appropriate action taken to minimise risk to staff and residents. Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 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 X 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 2 Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? NO 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 OP38 Regulation 13 [4] Requirement The registered manager must ensure the health, safety and welfare of residents and staff, through a risk assessment strategy. Timescale for action 09/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Osborn Manor DS0000011768.V263905.R01.S.doc Version 5.0 Page 21 - 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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