Inspection on 15/11/07 for Ovenden House

This inspection was carried out on 15th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Ovenden House 06/05/09

Ovenden House 07/05/08

Ovenden House 04/12/06

Ovenden House 22/05/06

Ovenden House 09/11/05

Ovenden House 26/07/05

Ovenden House 06/09/04

Ovenden House 18/05/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Ovenden House Ovenden Road Ovenden Halifax West Yorkshire HX3 5QG Lead Inspector Lynda Jones Key Unannounced Inspection 15th November 2007 09:45 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 Ovenden House DS0000059091.V355016.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. Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ovenden House Address Ovenden Road Ovenden Halifax West Yorkshire HX3 5QG 01422 362487 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) ovenden@pcslimited.net Pennine Care Services Ltd vacant post Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th December 2006 Brief Description of the Service: Ovenden House is owned by Pennine Care Services Limited and is registered to provide accommodation and care for up to twenty-three older people. It is a stone built detached period property situated in a residential area in the Ovenden district of Halifax, with easy access to the town centre by public transport. Accommodation is provided in thirteen single and 5 shared rooms. Externally, there are garden areas for people to enjoy in the warmer weather with parking facilities for staff and visitors. The current weekly charge at the home is £349.60 for a shared room and £366.10 for a single room. Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last key inspection took place in December 2006. We also carried out a random inspection of the home on 15 May 2007 because we received an anonymous complaint about medication practices in the home and about the attitude of a senior member of staff. On that visit, we found the medication practices in the home satisfactory. We asked the owner of the home to conduct an investigation into the attitude of the member of staff. This inspection was carried out to assess the quality of care provided to people living at the home. At the time we visited, there were 13 people living there. Two inspectors carried out this inspection over one day between 9.45 am and 5 pm. We talked to people who live there and to visitors who called in. We also talked to the staff on duty. We observed care practice, looked at various records and looked round the home. Before the visit, we asked the home owner to complete a self-assessment form. This was not returned by the date we requested, this meant we were delayed in sending out surveys to people who have contact with the home and they could not be returned to us until after the visit took place. We sent surveys to a sample of people who live at the home and to the relatives of the 13 people living there. We also wrote to health care providers that have contact with some of the people who live there. We received replies from 5 relatives. The surveys give people the opportunity to tell us what they think of the service. The information we get is shared with the home but we do not say who has provided it. In preparing this report we have considered the information from the surveys and any other information we have received about the home since our last visit. What the service does well: People are well dressed and, from their appearance, they look cared for. Relatives who wrote to us said they are generally satisfied with the service provided. The staff are friendly and they make visitors feel welcome. Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 6 People are assessed before they move in to make sure their needs can be met. What has improved since the last inspection? What they could do better: People need to be involved in drawing up their care plan. If some individuals cannot take part, their relatives/friends should be consulted. This will give people the opportunity to say whether their care suits them or could be improved in any way. Information in the care plans should give clear instructions to staff about what they must do to make sure people’s needs are met. Information about people’s health care needs should be recorded in one place, ie, in their own personal records. The care plans should be reviewed regularly and they should be amended when people’s needs change. The reviews should be detailed and not just a tick box exercise. The staff must have more training and support to make sure they have the skills and knowledge they need to support people properly. The home owner and the manager need to consider why so many accidents are taking place and consider what preventative action they can take to make sure that people are safe. The management of medication must be improved so that it can be accounted for at all times. Records must be improved and people must be given their medication as it is prescribed by their doctor. The home must provide some stimulating activities for people to take part in and staff need to have more contact with people. People are spending most of their days sitting in the lounge with nothing to occupy them. The manager and home owner need to meet with relatives and ask them what they think of the service provided. They need to make sure that people feel confident about raising concerns and know that their views will be taken seriously. All staff need more training so that they are aware of their duty to make sure people are safe and protected from possible abuse. Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 7 A complaints log should be set up. Details of the complaint, any investigation and action taken needs to be recorded. The environment must be improved. The furnishings and fabric of the building have now deteriorated to such an extent that they are no longer of an acceptable standard. It is important that a manager is registered. This will mean that there is someone legally responsible for the direct management of the home. The home must notify us of deaths, illnesses and any other events that adversely affect the wellbeing of people who live there. This will allow us to check that appropriate action has been taken. 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. Ovenden House DS0000059091.V355016.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 Ovenden House DS0000059091.V355016.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): 1&2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed before they move in. This tells the home about the type of support and care they will need. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which gives people some information about the home. At our last visit we said this must be updated so that it accurately reflects the service and facilities that can be provided. This work has been completed. Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 10 The manager said people are welcome to visit the home to see if their support and accommodation needs can be met there before making any decision about moving in. People are assessed before they move in to make sure the correct care and support can be provided. The home does not provide intermediate care. Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are not always receiving the care and support that they need. They are not involved in their care plans, nor are their relatives. Some people do not get the care they require because the staff do not have sufficient understanding of the needs of people with dementia. People are not always given their medication as prescribed by their doctor. EVIDENCE: We looked at the care records of four people. None of the records we looked at showed that people are involved in drawing up or reviewing their care plans. The evidence shows that relatives of people Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 12 with dementia are not routinely consulted about the care plans even though they visit the home regularly. One relative wrote to us saying they had never seen a care plan. We could only find evidence of the involvement of relatives in the annual reviews arranged by Calderdale Social Services. We looked at the records for one person who was at the home for a short stay. We found a pre-admission assessment, which contained some useful information. We could not find out when this person moved in and we could not find a care plan. This means that there is no information for staff about the health, social and personal care needs of this individual. We are not confident that people are always receiving the health care that they require. Information about health care needs is recorded in different places which means there is a risk that important information could be overlooked. Some information is in the daily records that are kept with the care plan. Other important health care information is kept in a “handover book.” This is a bound book that contains day to day information about all of the people who live there. Any records relating to an individual living at the home must be kept separately so that people can access their own records without seeing information about other people. This makes sure that the home complies with the Data Protection Act 1998. On one set of records we looked at, we noted that staff had recorded the changes they observed in the health of one person over several months. There was no evidence that anyone had an overview of this person’s changing needs. For example, no one called a review to see if care could be improved in any way or to see if this persons needs could still be met at the home. Individual risk assessments are reviewed on a monthly basis, although in some cases this appears to be a “tick box exercise”. In the records, we read about significant changes in the needs of one individual but the risk assessments and care plan had not been altered to reflect these changes. The records suggest that some of the staff do not have sufficient understanding of the needs of people with dementia. We could find no clear guidance for staff about how to manage potentially challenging behaviour. Staff are left to manage situations as they feel fit. The records show that some staff have the skills to defuse a situation, others do not. Some of the situations described and language used in the records is inappropriate and confrontational. In the surveys, three people told us said they were satisfied with the care provided and felt that their relatives’ needs were met. One person said “basic needs are met very well”. One person told us they had to ask for teeth to be cleaned and for their relative to be given a shave. We do not feel that personal hygiene is always Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 13 given sufficient priority, for example, we noted that one person had only been helped to have a shower six times in five months. There was nothing in the records to say whether there was a reason for this. We are concerned at the number of falls that people are having. We looked at the records for one month and counted ten accidents. On two occasions paramedics were called to the home, one accident in this period resulted in a hospital admission. One person who contacted us said her relative had an accident and sustained an injury that had gone untreated until she took him for medical treatment. We have not been notified of this accident. The manager could offer no explanation for the number of accidents. There was no evidence of any attempt to analyse the information and try to prevent so many accidents happening. Medication is not well managed and people are not always receiving the medication that has been prescribed for them by their doctors. We found gaps on the records where medication had been given but had not been signed for. We found evidence that prescribed medication is not always being given at the correct times or with the correct frequency. It is not possible to track all of the medication held in the home. In some cases, the amount of medication held could not be reconciled with what was recorded on the medication record sheets. One person told us that the home had been slow to obtain prescribed pain relief medication for their relative, they felt that this was due to poor communication between staff. Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People do not have a quality social life because there is very little taking place in the way of stimulating activities and very little meaningful interaction between staff and people who live there. This means that individuals can be left for long periods without moving about and without anyone talking to them. EVIDENCE: There is no evidence of any stimulating activity ever taking place. The manager told us some games had been purchased recently and we saw some equipment in the small lounge but there is nothing in the records to indicate that activities take place. We saw very little interaction between people who live there and staff in the 7 hours we were there. Staff only had contact with people when they were giving out drinks, taking people to the toilet or taking people to the dining room at lunchtime. The staff on duty spent most of their time in the dining room while everyone was left sitting in the lounge. They entered the lounge when they Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 15 saw someone get up out of their chair who was at risk of falling. Contact was brief, people were asked to sit down, then the member of staff left the room. Most people spent the majority of the day sitting in the lounge in silence. There are two TVs in the room, one at each end. One TV set is digital and one is not; this means that, although the same station is on each TV there is a delay in the sound production which causes an echo in the room. The staff said they had not noticed this. No-one watched TV all day, the sets are switched on as a matter of course. Two out of 5 relatives commented on the lack of activities. One person told us “I have stressed the need for entertainment for the residents who largely just sit around and doze, with little or no attempt to occupy them”. Another said they should “encourage more interaction between residents and staff and have more conversations with those who would enjoy that”. People’s lifestyles and chosen diets are not respected. We were told about one person who was a lifelong vegetarian and staff were informed about his diet. In the survey we were told “they observed his choice for a short time, then he was given whatever everyone was having”. We discussed this with the manager during feedback at the end of the inspection but we could find no explanation for the change of diet. At tea time, people were served either a slice of pizza and chips or burger and chips which looked unappetizing and lacked nutritional value. People were having difficulty eating the pizza. When we asked what it was like, one person said it was “awful” and banged the pizza slice on the edge of the table to demonstrate how hard it was. Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 16 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): 16,18. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People need to be confident that, if they raise concerns about the service, they will be acted upon. Sometimes people do not feel that their concerns are being listened to and taken seriously. People are not properly protected and safeguarded from abuse. Staff need additional training so that they are clear about their responsibility to make sure people are safe. EVIDENCE: People who returned the surveys said they know about the complaints procedure and they know what to do if they have any concerns about the service. Not everyone feels confident that their concerns are listened to, one person told us that making a complaint to management is difficult but we do not have any more information about why this is so. There is no complaints log that gives an overview of the number of complaints made, what they were about and how they were dealt with. We know from the Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 17 information provided before the visit that there have been three complaints in the past twelve months but it was not easy to find any details about them. From the daily records we noted that a relative had made a complaint during an annual review meeting about the poor state of a bedroom and clothes that had been damaged in the laundry. The manager assured us the matter has been dealt with but, without a complaints log, there is no quick way of checking this. We discussed this at the feedback session and the manager said she would set up a record for complaints. We are not confident that people are being protected from possible abuse. We raised concerns with the manager about some incidents that we read about in the daily records, which indicate that people may be at risk. Appropriate risk assessments need to be carried out to make sure that people are properly safeguarded and staff need additional training so that they know what to do if they suspect someone is at risk. Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 18 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): 19,21,24,25,26. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is in a poor state of decoration and repair and does not provide a pleasant, hygienic place for people to live. EVIDENCE: The dining room and small lounge have been decorated recently and new carpets have been fitted, improving the look of both rooms. The rest of the house is in a very poor condition. The poor state of bedrooms and bathrooms gives the impression that people who live there are not Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 19 respected. Some people have their own personal possessions in their rooms, other rooms look bare and impoverished. The health and safety of people who live there is at risk because repairs are not being carried out. The home is not clean and some working practices do not help to reduce the risk of cross infection. These are some of the things we saw and talked to the manager about during feedback: • • • • • • • • • • • • • Many of the bedrooms have not been decorated for years. The wallpaper in some rooms is ripped. Many of the rooms have non-slip flooring, some floors are not clean. In some rooms the floor covering is split, it poses a trip hazard and is unhygienic. Most of the mirrors and windows in bedrooms are dirty. Some of the wall lights are not working. In one room, the light switch does not always work, in another room bare wires have been left exposed where a wall light has been removed. One of the door closures is broken and hanging off. One door handle is hanging off. One of the bed heads is loose. Radiator guards have not yet been fitted in all rooms, which means that people may be at risk of burning themselves. In some rooms there are no paper towels, no soap and no plugs for the sinks. In one room, the sink was blocked and the plughole was dirty. Tooth denture pots in bedrooms are dirty. Some of the towels that are in use are frayed and thin. There are no waste bins in some of the rooms. Used tissues had been left on window ledges and on tops of drawers. Used incontinence pads had been left in a bin in one room. In another room, a wicker type laundry basket is being used as a bin for soiled pads. Some of the commodes are ripped and unhygienic. In one room, the lid of a commode had been left on top of the bed. Some of the bedroom furniture and carpets are stained. Some bedrooms smelled of urine. Soiled underwear was left on the floor in one room. We have been told about a recent outbreak of sickness and diarrhoea at the home. The home failed to notify us of this and tell us what measures were in place to prevent the spread of infection. Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 20 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): 27,28,29,30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are not always receiving the care and support that they require. The staff need additional training so that they understand what they must do to meet people’s needs properly. EVIDENCE: The duty rotas show that there are two care staff on duty throughout the day and night. The manager is on duty during the day from 8 am. There is a cook and cleaner on duty each day. The cook works until 2.30 pm each day; when she has a day off, a member of care staff comes in to prepare meals. The care staff prepare and serve the meal at tea time. We looked at a sample of staff files to see if checks are carried out on staff before they start work at the home. On one file, we could not find evidence of a Criminal Records Bureau check being carried out, on two files we could not find an application form. The manager said this was most likely because some staff at the home were originally employed to work on the home care service Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 21 that the company used to provide. We have asked the manager to get this information and keep it with the relevant file. According to the self assessment information, three care staff have completed NVQ level 2 and the remaining nine staff are currently working towards this qualification. The staff need additional training on how to care and support people with dementia. Some staff are not as patient as others and some practices we read about could result in confrontation with people. One relatives told us “some of the staff can be very caring, others have no idea how to talk to residents or how to care”, another said “some carers are very good, some treat it as just a job and residents’ needs are not considered important”. Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 22 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): 31,33,35,37,38. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is not well managed. More needs to be done to make sure the health and safety of people living in the home is protected. The building is not well maintained and people are having a lot of accidents. EVIDENCE: There is no registered manager at the home. The current acting manager has been in post since September 2006 and has not applied for registration with us. We made a requirement in the last report from December 2006 for the manager to submit an application. Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 23 It is important that a manager is registered. This will mean that there is someone legally responsible for the direct management of the home. At the moment, the owner has legal responsibility for the management of the home. The home is not well managed. People are not always receiving the care that they need and they are not being properly protected and safeguarded from abuse. The company has nominated a senior manager to carry out monthly visits to the home. The purpose of these visits it to monitor the quality of the service being provided, to give support to the manager and to provide feedback to the owners by way of a written report. The most recent report available was done in September 2007, it was not clear if any visits have been carried out since then. The manager should meet with relatives and ask for their opinions about the way the home is managed. One of the relatives told us they found the informal way the home was run has an attractive side but went on to say “we feel a more organised approach would be helpful in some circumstances”. The home is failing to notify us of deaths, illnesses and any other events that adversely affect the wellbeing of people who live there. The last notification we received was in July 2007. We are aware that there has been an outbreak of illness in the home in October 2007 and some people have had accidents which have resulted in admission to hospital but the home failed to notify us of these events. We are concerned about the health and safety of people living at the home because of the poor maintenance of the building and we have outlined some of the issues in this report. Representatives of Calderdale Council also made a visit to the home earlier in November 2007 because of their concerns about health and safety issues. The home owner has been asked to provide copies of risk assessments and records showing that equipment has been safely maintained. The manager holds some money for people for safekeeping purposes. This is usually money deposited by relatives for hairdressing. We looked at some of the records and checked that the money held for safekeeping matched the records. We saw in the daily records that a relative had left money for someone and it had been placed in the medicine cabinet for safekeeping. When we checked, the money had been moved but it had not been logged on the finance records. This is poor practice. The money was accounted for the following day. Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 24 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 3 3 X X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X 1 X X 1 1 1 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 X 2 1 Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 25 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 Requirement Timescale for action 28/02/08 2 OP7 15 3. OP9 13 (2) 4 OP12 16 People who use the service (or their representatives) must be consulted about what is in their care plans. This will give people the opportunity to comment on the care and support provided and say if it could be improved. Care plans must be reviewed to 28/02/08 make sure they: a) Contain up to date information about people’s needs. b) Indicate clearly the action that staff need to take to meet people’s needs. This will make sure that individual needs are met appropriately. 14/12/07 All prescribed medication administered to people living in the home must be signed for on the medication administration charts. This will make sure that people must be given their medication as prescribed by their doctor. Activities must be provided that 31/01/08 meet the range of needs and abilities of the people who live there. Wherever possible, people DS0000059091.V355016.R01.S.doc Version 5.2 Ovenden House Page 26 5 OP15 16 6 OP16 Schedule 4 7. OP18 13 8 OP19 23 9. OP25 23 10. OP29 19 11. OP31 7 must be consulted about the sort of activities they wish to be involved in. This will enable them to take part in activities of their choice. People must be provided with an appealing, wholesome and nutritious diet, which suits their individual requirements. This will make sure people get food that they like. A record must be kept of all complaints made which includes details of investigation and any action taken. This is so that people can know their complaints will be taken seriously and acted upon. Staff must make sure that they use the local adult protection procedures and report any incidents of abuse. This will help to keep people safe and protected. The premises must be upgraded and refurbished to make sure that it is decorated and furnished to an acceptable standard. This will make sure that people live in a pleasant, hygienic and comfortable home. Guards must be fitted to radiators. This will make sure that people are not at risk of burning themselves. Previous timescale of 31/05/07 not met. All of the necessary checks must be completed before staff start working in the home. This will make sure that staff are suitable to work with older people. The acting manager must submit an application to CSCI to be registered as manager of the home. This will make sure that there is a suitable qualified and competent person in charge of DS0000059091.V355016.R01.S.doc 14/12/07 31/12/07 14/12/07 30/04/08 31/01/08 14/12/07 31/01/08 Ovenden House Version 5.2 Page 27 12. OP38 37 13. OP37 17 the home. Previous timescale of 31/05/07 not met. The home must notify the Commission of all events that adversely affect the wellbeing of people who live there. This will make sure that we can check that the proper action has been taken. Records relating to each person must be held separately and not in bound books. This will make sure that all of the information about people’s needs is in one place and kept confidential. 14/12/07 31/01/08 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 Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Ovenden House DS0000059091.V355016.R01.S.doc Version 5.2 Page 29 - 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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