CARE HOMES FOR OLDER PEOPLE
Ovenden House Ovenden Road Ovenden Halifax West Yorkshire HX3 5QG Lead Inspector
Cheryl Stovin Unannounced Inspection 25th November 2005 13:30 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.V267303.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. Ovenden House DS0000059091.V267303.R01.S.doc Version 5.0 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.V267303.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26th July 2005 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. Ovenden House DS0000059091.V267303.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over three visits, on 9th, 14th and 25th November 2005. Four service users and several members of staff were consulted as to their views on the standard of services and facilities provided within the establishment. The residents spoken to all expressed great satisfaction with the facilities and care they receive at Ovenden House. Concerns were identified during the inspection regarding staffing and management arrangements, some environmental issues and care planning. What the service does well: What has improved since the last inspection? What they could do better:
The establishment is experiencing problems recruiting and retaining members of staff, resulting in a number of staff vacancies. Some members of staff are covering vacant shifts, others are not able to do so, which has resulted in the management team having to cover shifts often at short notice. This has resulted in both the acting manager and the deputy manager resigning from their posts and both are currently working their notice. Two bedrooms within the home have been affected by damage caused by damp and remedial work must be undertaken before they can be occupied by service users. New care planning documentation has been implemented by the home, however, care should be taken to ensure that the document is completed to enable an individual plan of care to be in place for each service user.
Ovenden House DS0000059091.V267303.R01.S.doc Version 5.0 Page 6 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.V267303.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 Ovenden House DS0000059091.V267303.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): None of these standards were assessed on this occasion. EVIDENCE: Ovenden House DS0000059091.V267303.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): 7,8 There is a lack of attention to detail in the care planning documentation. EVIDENCE: New care planning documentation has recently been implemented within the home. The case files of the most recently admitted service users were examined and it was found that, in some cases, entire sections of the care plan had not been completed, and in two case files nothing had been completed at all. Standard 7 of the National Minimum Standards for Care Homes for Older People states “the service user’s health, personal and social care needs are set out in an individual plan of care”. Ovenden House DS0000059091.V267303.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): None of these standards were assessed on this occasion. EVIDENCE: Ovenden House DS0000059091.V267303.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): 16,18 The home has robust systems to ensure that service users are safeguarded from abuse and that complaints will be dealt with promptly. EVIDENCE: The establishment holds a clear complaints procedure which is displayed in the entrance hall of the home. All staff have received training in adult protection awareness and procedures. Ovenden House DS0000059091.V267303.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): 19,20,23,24 Some areas of the home are in need of urgent remedial attention to rectify problems with damp. EVIDENCE: The establishment is situated in a residential area in the Ovenden district of Halifax and on a bus route to the town centre. The property, a large stone built period residence has been in the process of redecoration and refurbishment throughout. The conservatory, small lounge and dining room, and several bedrooms have already been refurbished and new carpets fitted. The appearance was bright and cheerful and welcoming, however, no further refurbishment has been completed since the last inspection. Two of the bedrooms were noted to be damp, one was not in use as the problem was so severe. The establishment provides accommodation in thirteen single bedrooms and 5 shared rooms, with only two bedrooms being equipped with en-suite facilities.
Ovenden House DS0000059091.V267303.R01.S.doc Version 5.0 Page 13 There is no screening provided within the shared bedrooms and no lockable facility in the majority of the bedrooms. Ovenden House DS0000059091.V267303.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 The home is experiencing problems in the recruitment and retention of staff. EVIDENCE: At the time of the inspection there were the following staff vacancies: 2 day care assistants, 1 part time cook, 1 senior care assistant, 1 night care assistant, a gardener and a handyman. Some staff are covering by working extra shifts, however, others are reluctant to do so, leaving the manager and deputy manager having to cover shifts, often at short notice, which is unsatisfactory. The Registered Provider has indicated that agency staff will be employed to cover vacant shifts, especially over the Christmas period. Staff files examined indicated that one new member of staff had been employed by the home without a POVA check and a CRB disclosure had been accepted from their previous employer. Ovenden House DS0000059091.V267303.R01.S.doc Version 5.0 Page 15 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32 The home is without a Registered Manager and both the members of the management team are working their notice, therefore, management arrangements within the establishment are unsatisfactory. EVIDENCE: The acting manager and the deputy manager of the home have tendered their resignation and are to leave shortly. The Registered Provider has indicated that a manager from another establishment within the organisation will be transferred on a temporary basis until a permanent manager is recruited. Ovenden House DS0000059091.V267303.R01.S.doc Version 5.0 Page 16 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 1 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 3 x x 2 x x x STAFFING Standard No Score 27 2 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 x x x x x x Ovenden House DS0000059091.V267303.R01.S.doc Version 5.0 Page 17 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. Standard Regulation Requirement Timescale for action 31/01/06 1 OP33 26 2 3 4 OP19 OP31 OP7 23 9 15 Visits to be undertaken in accordance with Regulatiion 26 of the Care Homes Regulations and a report provided to the CSCI. This remains outstanding from the previous report. Areas of damp within the home to be rectified. Suitable management arrangements to be in place. A service user plan of care to be generated to provide the basis for the care to be delivered. 31/01/06 31/12/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP10 OP24 Good Practice Recommendations Screening to be provided in shared rooms. A lockable facility to be provided in each service users bedroom. Ovenden House DS0000059091.V267303.R01.S.doc Version 5.0 Page 18 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
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