Inspection on 22/05/06 for Ovenden House

This inspection was carried out on 22nd May 2006.

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 15/11/07

Ovenden House 04/12/06

Ovenden House 09/11/05

Ovenden House 26/07/05

Ovenden House 06/09/04

Ovenden House 18/05/04

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Snydale Care Home

Larchfield Manor

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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 Cheryl Stovin Unannounced Inspection 22nd May 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ovenden House DS0000059091.V293627.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.V293627.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) Pennine Care Services Ltd Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th May 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. The establishment, a stone built detached period property, is situated in a residential area in the Ovenden district of Halifax with easy access to the town centre by public transport. Accommodation within the establishment is provided in thirteen single and 5 shared rooms. Externally there are garden areas for the service users to enjoy in the warmer weather with parking facilities for staff and visitors. No information has been supplied by the home as to the weekly charge. Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to a Key Inspection of Ovenden House which was undertaken on 22nd and 23rd May 2005 by two inspectors from the Commission for Social Care Inspection. A total of 15 hours was spent on the site visit. A random inspection was undertaken on 8th May 2006, and reference to this inspection is included in the main body of this report. In addition to the site visit to the home, when service users were consulted, relatives/visitors were invited as to their opinions of the services and facilities provided within the home by the completion of a comment card. Two replies were received. A pre-inspection questionnaire was sent to the home, however, this document was not returned. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk What the service does well: What has improved since the last inspection? As a result of requirements made at the Random inspection undertaken on 8th May 2006, additional staff have been brought into the home from other establishments and agencies within the company. This has improved the levels of staff on duty. In addition, new staff have been recruited and are awaiting POVA first checks prior to commencing employment. Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 6 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. Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 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 Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 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): 1,3,6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide does not reflect the current situation within the home, therefore service users do not have the information they need to make an informed choice about moving in. Pre admission assessments do not appear to have been carried out, therefore staff cannot be sure that they can meet the service users needs before they are admitted. EVIDENCE: The establishment has produced a Statement of Purpose and Service User Guide, however, the document is out of date and requires revising to reflect the current situation within the home. Service users records examined did not contain evidence of pre-admission assessments being carried out. Intermediate care is not provided within the establishment. Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 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): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Limited information is available to assess that service users’ health and personal care needs are being met. Service users’ are not always treated with privacy and respect. EVIDENCE: Care planning documentation is in place, however, record keeping is poor. Care plans are not reviewed and entire sections of the documentation are not completed, giving no indication of how service users’ needs are to be met. One service user had been seen by GP regarding poor dietary intake, but no nutritional assessment had been carried out and no follow up recorded. One service user had been assessed as having a moderate risk of pressure sores, however, no information was in place as to how the risk will be managed. One service user has an Alpha Excel pressure relieving mattress on her bed, however, staff were not aware of why it is there, or who arranged it, or even if it is actually for her. There was no evidence that service users’ or their relatives were involved in the care planning process. Moving and handling assessments are not clear, and the inspectors observed very poor practices in manual handling techniques posing potential risk to both service users and Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 10 staff. Daily records are not used in conjunction with care plans and give very little information. An example of this was a service user admitted to hospital during the night, no information was recorded of why an ambulance was called and whether their relatives had been informed. Service users are not treated with respect at all times, the poor manual handling technique previously referred to seriously impacted on the persons dignity. The establishment uses a Nomad system supplied by a Bradford pharmacy for the administration of medication. The medication is securely and appropriately stored and stocks held reconciled with records kept. All senior staff responsible for administering medication have received appropriate training. A drugs fridge is provided, however, eye drops held in the fridge had not been dated when opened. One inspector, on the second day of the inspection, observed a member of staff administering medicines, not using a medicine pot, but putting the tablet in her hand and giving to the residents. Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Daily routines within the home are not flexible and no activities are provided to enable the service users social and recreational needs to be met. EVIDENCE: There are very limited activities provided within the home. Staff said there was no time for activities and service users confirmed that staff did not have time to sit and chat to them. The daily routines are, for the most part, organised around a series of tasks to be completed, and although service users can get up and go to bed when they want, there is very little for them to do between getting up and going to bed. Service users, with whom the inspectors consulted, expressed general satisfaction with the standard of the meals provided within the home. The home has a three weekly menu but this is not always followed, for example, burgers were being prepared for tea, although the menu stated quiche and salad. The full time cook has a good knowledge of service users dietary needs and preferences although these are not recorded. Service users’ confirmed that she always asks them what they want to eat, but said that this does not happen when she is not on duty. On the second day of the inspection a different cook was on duty and service users were not consulted about their Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 12 choice until they were sat at the dining table. One service user requested a meal without gravy and as the two meal options were a casserole and a stew staff struggled to meet this request. One service user with a recent injury to her hand was struggling to eat her food and the inspector intervened to ask staff to assist her. Staff were told by the cook that there was no alternative dessert and no diabetic dessert was available. This incident was dealt with following intervention by the inspectors. Visitors confirmed that they are made welcome when they visit the home. Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures are in place to safeguard the service users from abuse. EVIDENCE: The establishment holds a complaints procedure, which is displayed in the entrance hall. The document requires updating as it refers to the National Care Standards Commission, and not the Commission for Social Care Inspection. A complaints log is held and any complaints received have been resolved satisfactorily. The establishment holds an adult protection and whistle blowing procedure. Protection of Vulnerable Adults training forms part of the initial induction training. Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 14 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): 19,20,22,23,24,25,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The establishment requires extensive refurbishment, redecoration and remedial work. EVIDENCE: The establishment is situated in a residential area in the Ovenden district of Halifax just off the main Ovenden Road. Vehicular access to the building from the main road is difficult due to the narrow gateway and heavy gates which are kept locked. Initial impressions of the home are poor, outside the front door there was a full rubbish skip with a dirty mattress thrown at the side of it, there were also some milk crates and a large cooking oil container thrown on the ground. Internally the home is in a poor state of repair, and although some bedrooms have been refurbished, the majority require attention. Odours were detected in many bedrooms. Many light bulbs required replacing and many call bells were without leads. Some bedrooms had no curtains or blinds. A fire detector was seen hanging from the ceiling in an upstairs corridor. Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 15 There were trailing wires in some rooms, some rooms had no hot water, and the ceiling was leaking in one room. A sliding door fell off the runners in one bedroom when the inspector attempted to close it. No screening is provided in shared rooms and the majority of service users have no lockable facility in their rooms. In one bedroom furniture had been removed to make room for a hoist. Fire doors were wedged open and there was broken cupboards, old blinds, and broken chairs piled up around a fire extinguisher. The majority of radiators are not fitted with guards. There is a problem with ventilation in the conservatory area, a lack of curtains or blinds leads to the room becoming unbearably hot, and with doors open and fans on there is a strong draught which is uncomfortable for the service users. The dining room carpet was noted to be dirty and requires cleaning or replacing. The laundry facilities are inadequate, the room is very small, with no room for clean and dirty pathways. There is no wash hand basin in the laundry, and no gloves or aprons were available. The kitchen facilities are adequate, however, the vinyl flooring is splitting where it has been joined. To the rear of the property is a large safe and accessible garden which was being cleared of rubbish at the time of the inspection. Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 16 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): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have been brought in to home from other establishments within the company to improve staffing levels. EVIDENCE: A random inspection was carried out on 8th May 2006 in response to concerns expressed regarding staffing levels within the home. At this inspection staffing levels were very low potentially affecting the health and safety of the service users. As a result of requirements made at that inspection additional staff have been deployed within the home from other establishments and agencies within the company. Duty rosters seen at this visit indicate that there are three care staff on duty between the hours of 8.30am to 9.30pm and two waking night staff. Staff rotas are being prepared on a weekly basis with a copy sent to the Commission for Social Care Inspection. The rotas only show Christian names. Some staff are working excessive hours to cover for staff on sick leave. The company has a standard induction training programme based on Skills for Care Standards, all new staff undertake this training at the headquarters in Bradford. NVQ training is provided within the establishment and 75 of permanent staff hold their award. Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 17 A number of staff recruitment files were examined which indicated that all the required checks are carried out before new staff start work. It was agreed during the inspection that newly recruited staff could start work on the basis of a POVA first check being carried out, under supervision, pending receipt of full CRB disclosure. Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Management arrangements within the home are not acceptable, there has been no Registered Manager for over two years. EVIDENCE: As a result of requirements made at the random inspection on 8th May the operations manager, has been brought into the home as temporary acting manager. There has been no Registered Manager in post for the past two years, there have been four acting managers during that time, all of whom left before being registered by the Commission for Social Care Inspection. The operations manager stated that the managers post has been advertised and interviews would be held shortly. Only the operations manager can access service users money and there is no petty cash float. Following discussions, she confirmed that a petty cash float will be available in the home, accessible by senior members of staff. The home does not act as appointee for any Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 19 residents. Some spending money is held on behalf of service users, a random selection was checked and cash held reconciled with records kept. It is recommended that two signatures be obtained for all cash transactions made and receipts obtained for any money spent on behalf of the service users. No quality assurance system is in place. Accident records were examined and contained very basic information with no follow up recorded It was stated that moving and handling training is updated regularly, however, the inspectors observed unsafe practice, with staff struggling to transfer a service user when they should have been using a hoist. Footplates were missing from many wheelchairs, a pile of discarded footplates were seen in one service users bedroom. Maintenance records were seen for hoists and stair lift which were up to date, as were the portable electrical appliances. A copy of the electrical wiring certificate was not available in the home. There was no copy of the gas safety certificate available, however, the operations manager contacted Gas Force who confirmed checks had been carried out last year and are due again in June 2006. Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 20 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 2 x 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 1 x 1 1 1 1 1 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 1 1 x 2 x x 1 Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 21 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 OP33 Regulation 26 Requirement Visits must be undertaken in accordance with Regulation 26 of the Care Homes Regulations and a report provided to the CSCI. This remains outstanding from the previous report. Previous timescales of 31/01/06 not met. The Registered Person shall provide a Statement of Purpose and Service User Guide which is up to date and accurate. Suitable management arrangements to be in place. This remains outstanding from the previous inspection. A service user plan of care to be generated to provide the basis for the care to be delivered. This remains outstanding from the previous inspection. New service users must not be admitted to the home without their needs having been assessed by a suitably qualified or trained person. DS0000059091.V293627.R01.S.doc Timescale for action 31/07/06 2. OP1 4 31/08/06 3. OP31 9 31/07/06 4. OP7 15 31/07/06 5 OP3 14 31/07/06 Ovenden House Version 5.2 Page 22 6 OP8 12 7 OP12 16 8 OP14 12 9 OP19 23 10 OP20 16 11 12 OP22 16 23 OP25 13 14 OP26 13 24 OP33 15 OP27 17 16 OP35 12 17 OP38 13 The Registered Person promotes and maintains service users health and ensures their health care needs are assessed. Particular attention must be paid to assessment of tissue viability. Activities must be provided within the home, and service users to be consulted about the programme of activities provided. Daily routines must be flexible to enable the service users to experience their preferred lifestyle. A programme of routine maintenance and renewal of the fabric and decoration of the premises must be provided. Discarded furniture and rubbish must be removed from the grounds. The dining room carpet must be cleaned. Call bell leads must be provided. Screening must be provided in shared rooms. Suitable screening must be provided in the conservatory to prevent excessive heat. Radiators must be guarded. Gloves and aprons must be available in the laundry area and a wash hand basin provided. An effective quality assurance and quality monitoring system based on seeking the views of the service users must be in place. Duty rotas must show which staff are on duty stating full names and in what capacity they are working must be kept. Arrangements must be in place to ensure that service users can access their money as and when required. Copies of electrical wiring and DS0000059091.V293627.R01.S.doc 31/07/06 31/07/06 31/07/06 31/07/06 31/07/06 31/07/06 31/07/06 31/07/06 31/08/06 31/07/06 31/07/06 31/07/06 Page 23 Ovenden House Version 5.2 18 19 OP9 13 13 OP38 gas safety certificates must be available for inspection. The Registered Person must 31/07/06 ensure that safe medication procedures are followed. The Registered Person must 31/07/06 make suitable arrangements to provide a safe system for moving and handling service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 4 Refer to Standard OP16 OP24 OP35 OP15 Good Practice Recommendations The complaints procedure should include details of the Commission for Social Care Inspection. A lockable facility to be provided in each service users bedroom. Two signatures to be provided when recording financial transactions on behalf of service users. Service users to be consulted regarding food served when the full time cook is not on duty. Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Ovenden House DS0000059091.V293627.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!