CARE HOMES FOR OLDER PEOPLE
Overdale 29-31 Kenwood Park Road Sheffield South Yorkshire S7 1NE Lead Inspector
Sue Turner Unannounced 18 July 2005 09:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Overdale Address 29-31 Kenwood Park Road Sheffield South Yorkshire S7 1NE 0114 255 0257 0114 255 0257 None Overdale Trust Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Ruth Helen Brown PC Care Home Only 25 Category(ies) of OP Old Age (25) registration, with number of places Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 1 February 2005 Brief Description of the Service: Overdale is a care home providing personal care for up to twenty-five older people. The home is situated in the Nether Edge area of Sheffield, close to bus routes and local ammenities. It is a detached victorian villa, set in its own pleasant gardens. Accomodation is provided on three floors, all accessed by a passenger lift. All of the bedrooms are single, a proportion have en-suite toilet facilities. Communal lounges and a dining room are provided. Sufficient bathing facilities are available, with aids and adaptations in place. The home is served by a central kitchen and laundry. Overdale is a non-profit making voluntary care home run by a committee of Christian people from various churches. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 3.5 hours from 9.00am to 12:30 mid-day. A second inspector was present at this inspection. An inspection of the environment was undertaken. A proportion of records were checked, including care plans, complaints, menu, rotas, staff training, recruitment, health and safety and fire records. Interactions between staff and residents were observed. Twelve residents, one relative, the majority of staff and one professional visitor were spoken with. One member of staff was formally interviewed. Discussions with the homes manager took place. What the service does well:
The interactions observed between residents and staff appeared caring and respectful. All of the comments made by residents were positive. They said that they were `very happy’, and `the home is first class’. Residents said staff were `very good’, `kind’, and `considerate, nothing is too much trouble’. The professional visitor spoken with said the home was `one of the best’, and `I would be happy for my own Mother to live here’. The relative spoken with said `the staff are excellent’. A service user guide had been provided to each resident to give him or her information about the home. The manager undertook assessments prior to admission, to ensure individual needs could be met. Trial visits took place, to enable prospective residents and their representatives to make informed choices. Staff undertook a range of training to keep them up to date and ensure they were able to meet residents’ needs. Care plans were in place for all residents. These were well set out and easy to read. They set out all aspects of personal, social and health care needs and recorded the staff action required to ensure all identified needs were met. Residents’ health care was monitored and access to health specialists was available. Residents confirmed that staff were respectful towards them. Residents spiritual needs were well met, any wishes regarding funeral arrangements were recorded to ensure these would be carried out. The routines at the home were flexible and residents were free to choose how to spend their day. A range of activities was available, which residents were free to participate in. All of the residents said they enjoyed the activities provided. There was an open visiting policy, to encourage contact with relatives and friends. The menu was varied, and choices were offered at mealtimes to respect residents’ preferences and maintain health. All of the residents said the food was `very good’, and `plentiful’.
Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 6 There was a complaints procedure and adult protection procedure in place, to promote residents safety. All of the residents said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. Residents said that they felt safe at the home. The environment was well decorated, well maintained, clean and fresh smelling. Communal areas contained homely touches to provide a comfortable environment. Bedrooms contained personal belongings, which enabled residents to have some control over their personal space. Sufficient bathing facilities were provided to ensure residents personal care needs were met. The central laundry and kitchen were well equipped to meet residents’ needs. Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were maintained. A recruitment procedure was in operation to ensure the safety of residents. A business plan was in place, and insurance cover was provided. Staff supervision took place, to support and give guidance to staff on an individual basis. Records within the home were stored securely, to safeguard confidentiality. Health and safety procedures were identified and carried out, and systems were checked and serviced to maintain a safe environment. Mandatory training took place, to equip staff with the essential skills needed. What has improved since the last inspection?
A proportion of the environment had been redecorated to maintain the high standards at the home. All doors had been redecorated and fitted with new handles. New dining tables and a new hoist had been purchased, and two bedrooms redecorated. In addition the homes computer systems had been updated. Staff training had been ongoing, the manager, assistant manager and two senior staff had achieved NVQ in management and care. Fifty per cent of the care staff had achieved NVQ level 2 in care, and a further four staff were undertaking the award. This is over and above the required levels and is to be commended. Since the last inspection the home had achieved the Investors in People award. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 and 5. standard 6 does not apply to this home. A statement of purpose and service user guide were available, to inform residents about the home. Contracts were drawn up with each resident. Assessments of needs were undertaken prior to admission to ensure that the needs of prospective residents could be met. Trial visits were encouraged to enable prospective residents to look around the home, meet residents, staff and give them the information needed to make informed choices. Staff undertook periodic training to keep them up to date and access to specialist services was arranged, in order that all assessed needs were met. The information available and actions taken ensured that standards were met. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 10 EVIDENCE: Each resident had a service user guide, to inform him or her about the home. These were provided in each bedroom, and copies of the service user guide and statement of purpose were on display in the entrance area of the home. Contracts (statements of terms and conditions) were drawn up with each resident upon admission, to inform them of their rights and obligations. Assessments of needs were in place, and copies of social workers assessments were obtained prior to admission, if available, so that a decision could be made about whether the residents’ needs could be met. All of the residents said the home met their needs. One resident said ‘we are very well looked after, the staff are wonderful’, and a further resident said `the home is second to none, I cannot think of anything else I need’. Residents confirmed that they had access to specialists at hospitals, and health professionals, such as dentists, opticians and chiropodists, so that all of their health care needs were met. Residents confirmed that they had been able to look around the home, stay for a meal and meet residents and staff, who provided them with the information they needed before choosing to move in Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 and 11. Each resident had a care plan, to give staff the information needed to ensure all care needs were met. Health care was monitored, assessed and met. Staff respected residents privacy and appeared respectful towards them. Procedures were in place to ensure residents were treated respectfully and sensitively when they were seriously ill. Residents’ wishes regarding funeral arrangements had been sought to ensure they were carried out. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 12 EVIDENCE: Care plans contained the full range of information required. These contained specific information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs were met. Residents were aware of their right to access their records, but those spoken to choose not to do so. Staff were aware of the contents of care plans and were knowledgeable about residents individual needs. Care plans were reviewed regularly to ensure that they were up to date and relevant information was recorded. The plans contained detail of all health care contacts, appointments and treatments, to ensure health was maintained. Residents’ health was monitored and access to specialists at hospitals, chiropodists, dentists and other health care professionals was available. Residents confirmed that they could see their GP and other professional visitors in private. A district nurse was visiting the home on the day of this inspection to attend to several residents. She reported a very good relationship with the home, and said that the home was `excellent’. Staff were observed respecting privacy by knocking on doors before entering. The interactions between staff and residents appeared respectful and caring. Residents made positive comments about their care. One resident said `I am very well looked after, the staff are marvellous’. Several residents said` the home is very good’. The wishes of residents were sought regarding death and dying, to ensure these were carried out. Staff had undertaken training on dying and death, to equip them with relevant skills. Three residents were seriously ill at the time of this inspection. Staff were seen to monitor their condition with care and respect. Systems had been put into place to ensure all staff were kept fully up to date on the care given and assessed need. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 Residents were able to make choices about how they spent their time. A range of activities was offered to residents, to promote choice and maintain interests. An open visiting policy was in place, in order to develop and maintain good relationships with residents’ family and friends. A varied menu was provided and choices were offered to respect personal preferences. EVIDENCE: Residents said they were able to get up and go to bed when they chose, and were seen to use different areas of the home according to their preference. A range of appropriate social opportunities were available, which included weekly quizzes, activities and trips out of the home. A visitor to the home provided the weekly quiz. This was taking place during the inspection, and was very well attended. Residents said that they really enjoyed the activities provided, and shared much laughter. Residents spiritual needs were addressed, and church services took place on a weekly basis at the home. Entertainers regularly visited the home. Residents confirmed that they were able to see their visitors in private. Those spoken to said their visitors could come at any time, and the home helped them maintain contact. One relative spoken with said that the care given at the home was `very good’. They said that the staff were always welcoming and were kept fully informed by the home.
Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 14 Residents were able to bring personal items with them into the home. All of the bedrooms were individually personalised and very homely. This was important to residents as it helped them retain control over their immediate environment. One resident said` having my own things around me makes a big difference, it really feels like my home’. The menu was varied and a balanced diet was provided to maintain residents health. Choices were offered on a daily basis. All of the residents said the food at the home was very good. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened to and taken seriously. An adult protection procedure was in place, to ensure residents safety was promoted EVIDENCE: Each resident and representative had been provided with a copy of the homes complaints procedure. This contained relevant detail and informed the reader of who to contact outside of the home to make a complaint, should they wish to do so. All of the residents said they had no concerns and could go to the manager and staff to sort out any worries they had. The home kept a record of complaints, which detailed the action taken and outcomes. The home had not received any complaints since the last inspection. An adult protection procedure was in place, which contained information on the Department of Health guidance `No Secrets’. Staff undertook training on adult protection to equip them with the skills needed to respond appropriately to any allegations. All residents said that they felt safe at the home. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 26. The home was maintained to a high standard. The environment was very clean, and fresh smelling. Appropriate facilities were provided to meet residents needs. All areas of the home were accessible. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and residents’ bedrooms were well decorated and personalised. EVIDENCE: The environment was decorated to a high standard. Communal areas were attractive, comfortable and the furniture provided was of a good standard. There was a pleasant garden, and garden seating was provided for residents’ enjoyment. All of the bedrooms seen were well decorated and highly individual, reflecting the residents’ personal taste. Bedrooms contained personal belongings, which enabled residents to have some control over their personal space. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 17 There were sufficient communal bathrooms and showers, with appropriate aids and adaptations in place, which met residents’ needs. Whilst the bathroom floors were clean, some bathrooms had marked flooring, due to wear from wheelchairs. A rolling redecoration programme was in place to maintain standards. All of the residents said that they were very happy with the accommodation provided. The homes kitchen and laundry contained the equipment needed to provide for residents. A maintenance programme was in place to ensure the home was kept safe and well maintained. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. Agreed levels of staff were being maintained. Some staff undertook NVQ training to improve their skills. Recommended levels of NVQ trained staff had been achieved. The homes recruitment practices ensured a thorough procedure was in operation. Some of the required documentation was not retained on staff files. Staff undertook periodic training to keep them up to date. A staff training plan and individual training records were kept to monitor staff training. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained. Residents felt that enough staff were provided. Of the sixteen care staff, seven staff had achieved NVQ level 3 and one level 2 in care. Four further staff were undertaking the training at level 3. The homes assistant manager and two seniors had achieved NVQ at level 4 in management and care. There was a thorough recruitment procedure, to uphold the safety of residents. Systems were in place to ensure CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks were carried out, to promote safe and efficient recruitment procedures. Staff files contained the majority of required information, and included written references from last employers. However, staff records did not evidence that gaps in employment history had been explored, to ensure safe procedures were carried out and risks minimised. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 19 Staff training records were maintained to ensure all staff had undertaken relevant training. Staff confirmed that they undertook induction and foundation training to familiarise themselves with the home and understand the requirements of their role. Staff said that they received sufficient training to be able to carry out their duties. Residents said that staff had the skills to do their job well. Staff appeared competent to carry out their duties; they displayed an understanding of individual residents needs and were able to give examples of good practice. The interactions between staff and residents appeared positive. Staff had a caring and patient approach. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,36,37 and 38. The management’s clear leadership benefited residents and staff. Regulation 26 visits by the responsible individual to monitor the service took place. Staff received formal supervision for development and support. The records were stored securely, to respect residents’ rights. Policies and procedures for the smooth running of the home and care of residents were in place and accessible to staff. Staff undertook mandatory training. A health and safety policy was in operation. Fire systems had been checked at the required frequency to ensure they were in working order. Some staff had not participated in a fire drill at the required frequency. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 21 EVIDENCE: The manager was experienced and qualified. Since the last inspection she had achieved NVQ level 4 in management and care. Staff and residents said the manager was approachable and supportive. Whilst formal staff supervision, to develop, inform and support staff took place, these did not take place at the required frequency of six times each year. Records were stored securely in the home to respect residents’ confidentiality. A health and safety policy was in place to protect staff and residents. Fire exits were clear and fire doors closed on their rebates. Records confirmed that fire-fighting equipment was checked and serviced, weekly checks of the fire alarm to ensure it was in working order had taken place. Staff were up to date with mandatory training to equip them with the essential skills needed to promote the well being of residents. Fire records evidenced that staff undertook fire training at the required frequency. However, some staff had not participated in a practice drill at the required frequency of twice each year to ensure essential skills were maintained up to date. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x 2 3 2 Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 23 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 29 Regulation 18 Requirement Timescale for action 30.09.05 2. 3. 36 38 18 13,18 Staff recruitment records must evidence that gaps in employment history have been explored. Staff supervision must take place 30.09.05 a minimum of six times each year. Staff must participate in a 30.09.05 practice fire drill a minimum of twice each year. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 21 Good Practice Recommendations The marked flooring in some bathrooms should be identified for replacement within the homes rolling redecoration and refurbishment programme. Overdale J55 S2996 Overdale V232685 180705 UI Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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