CARE HOMES FOR OLDER PEOPLE
Overdale 29-31 Kenwood Park Road Sheffield South Yorkshire S7 1NE Lead Inspector
Janis Robinson Unannounced Inspection 5th October 2005 08:45 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 Overdale DS0000002996.V254812.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. Overdale DS0000002996.V254812.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Overdale Address 29-31 Kenwood Park Road Sheffield South Yorkshire S7 1NE 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) 0114 255 0257 0114 255 0257 Overdale Trust Ms Ruth Helen Brown Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Overdale DS0000002996.V254812.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th July 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 DS0000002996.V254812.R01.S.doc Version 5.0 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 8.45am to 12:15pm. A partial inspection of the environment was undertaken. A proportion of records were checked, including, complaints, menu, rotas, staff recruitment, residents finances, medication, quality assurance and fire records. Interactions between staff and residents were observed. Five residents and the majority of staff were spoken with. One member of staff was formally interviewed. Discussions with the homes manager took place. The majority of standards were assessed and met at the previous inspection. 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’, ‘we’ve everything we need, when we need it’ and `the home is the best’. Residents said staff were `very good’, `kind’, ‘they (staff) spoil us’ and `considerate, nothing is too much trouble’. 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. 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’. There was a complaints 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. The environment was well decorated, well maintained, clean and fresh smelling. Communal areas contained homely touches to provide a comfortable environment. Overdale DS0000002996.V254812.R01.S.doc Version 5.0 Page 6 Agreed levels of staff were being maintained. A recruitment procedure was in operation to ensure the safety of residents. A quality assurance system, to seek the views of residents, was in place. A business plan was in place, and insurance cover was provided. Residents’ monies were managed appropriately. Some 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? 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 DS0000002996.V254812.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 Overdale DS0000002996.V254812.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): 4 and 5 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. EVIDENCE: All of the residents said the home met their needs. One resident said ‘we are very well looked after, the staff are kind and considerate’, and a further resident said `the home is the best, 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 DS0000002996.V254812.R01.S.doc Version 5.0 Page 9 One resident informed the inspector that they had been able to visit the home with their daughter several times before they moved in, and ‘this made me feel much better about coming to live here’. Discussions with staff confirmed that they undertook periodic training, for example; care planning, NVQ and first aid, to keep them up to date and equip them with the skills needed to carry out their duties. Overdale DS0000002996.V254812.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 10 The home had appropriate policies and procedures in place for dealing with residents’ medications. One administration record had not been recorded appropriately. Residents’ privacy and dignity was respected. EVIDENCE: All medication was stored securely. The staff that administered medication had undertaken training to ensure they followed safe procedures. There were systems in place to enable residents to handle their own medication, if assessed as able to do so. There was appropriate storage for controlled drugs, and a controlled drugs register, signed by two staff at each administration, was in use. Medication administration records tallied with the medicines held. One resident had been asleep at the time of the morning medicine round. Their administration record had not been signed to evidence this, but had been left blank for the morning. Overdale DS0000002996.V254812.R01.S.doc Version 5.0 Page 11 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 patient and gentle when they help me (shower)’. Several residents said` the home is very good’. Overdale DS0000002996.V254812.R01.S.doc Version 5.0 Page 12 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 and 15 Residents were able to make choices about how they spent their time. A range of activities was offered, 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. During the inspection, a relaxation session was being run by a visitor to the home, 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. Residents were able to bring personal items with them into the home.
Overdale DS0000002996.V254812.R01.S.doc Version 5.0 Page 13 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. One resident told the inspector `when I first came to the home, the staff asked me what food I like and dislike, I never get any food I don’t like’. Overdale DS0000002996.V254812.R01.S.doc Version 5.0 Page 14 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 and 17 A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened to and taken seriously. Residents legal rights were protected. 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. Residents confirmed that they were able to vote at election time, as the manager had arranged postal votes for them. Whilst all of the residents had representatives or relatives, the manager was aware of how to access advocacy services and had done so in the past for residents that needed external representatives to look after their interests. Overdale DS0000002996.V254812.R01.S.doc Version 5.0 Page 15 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 and 20 The home was maintained to a high standard. 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. Sufficient bathing facilities were provided. EVIDENCE: The environment was decorated to a high standard. All areas of the home were very clean, and fresh smelling. Communal areas were attractive, comfortable and the furniture provided was of a good standard. Different lounge areas were provided throughout the home to give residents a choice. There was a pleasant garden, and garden seating was provided for residents’ enjoyment. There were sufficient communal bathrooms and showers, with appropriate aids and adaptations in place, which met residents’ needs. Whilst the bathroom floors were clean, one bathroom had marked flooring, due to wear from wheelchairs. This room had been identified for refurbishment. Residents said the home was `lovely and comfortable’.
Overdale DS0000002996.V254812.R01.S.doc Version 5.0 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 and 29 Agreed levels of staff were being maintained. The homes recruitment practices ensured a thorough procedure was in operation. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained. Residents felt that enough staff were provided. 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 required information, and included written references from last employers. Since the last inspection staff records had been updated to evidence that gaps in employment history were explored, to ensure safe procedures were carried out and risks minimised. Overdale DS0000002996.V254812.R01.S.doc Version 5.0 Page 17 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): 32,33,34,35,36,37 and 38. The management’s clear leadership benefited residents and staff. Regulation 26 visits by the responsible individual to monitor the service took place. A quality assurance system was in operation. The home had a business plan. Residents’ monies were managed safely. Staff received formal supervision for development and support. This needed to take place at the required frequency. 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 DS0000002996.V254812.R01.S.doc Version 5.0 Page 18 EVIDENCE: Staff and residents said the manager was approachable and supportive. Annual surveys to obtain the views of residents regarding the care provided were undertaken. The results of the surveys were audited and included in the service users guide. The home had business and financial plans. Insurance cover was in place. Small amounts of spending monies were held for residents. These were stored securely. Records were accurate and up to date. 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 DS0000002996.V254812.R01.S.doc Version 5.0 Page 19 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 x 3 3 3 x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 3 3 3 2 3 2 Overdale DS0000002996.V254812.R01.S.doc Version 5.0 Page 20 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 OP9 Regulation 13 Requirement Timescale for action 01/12/05 2 3 OP36 OP38 18 13,18 Medication administration records must be completed in full at all times. When medicine has not been administered at the identified time, the record must reflect this. Staff supervision must take place 01/12/05 at the minimum frequency of six times each year. Staff must participate in a 01/12/05 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. Refer to Standard Good Practice Recommendations Overdale DS0000002996.V254812.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Sheffield Area Office 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
© 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 Overdale DS0000002996.V254812.R01.S.doc Version 5.0 Page 22 - 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!
