Inspection on 07/11/05 for Oxendon House

This inspection was carried out on 7th November 2005.

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

Oxendon House 25/02/08

Oxendon House 13/03/07

Oxendon House 07/04/05

Oxendon House 17/08/04

Oxendon House 07/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Oxendon House 33 Main Street Great Oxendon Market Harborough Leics LE16 8NE Lead Inspector Ms Sarah Jenkins Unannounced Inspection 7th November 2005 07:30 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 Oxendon House DS0000040280.V261057.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. Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Oxendon House Address 33 Main Street Great Oxendon Market Harborough Leics LE16 8NE 01858 464151 01858 461646 anniegjohnson@ntlworld.com 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) Oxendon House Care Home Limited Ms Gwendolyn Ann Johnson Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability over 65 years of age (7) of places Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No one falling within the category of PD(E) maybe admitted into the home where there are 7 persons of category PD(E) already accommodated within the home. To be able to admit the named person of category DE(E) as agreed the previous registration authority in 2002 2. Date of last inspection Brief Description of the Service: Oxendon House is a care home providing personal care for 27 older people, including up to 7 people who may have additional physical disabilities. The home is located in the rural village of Great Oxendon, which is between Northampton and Market Harborough, the latter being 3 miles away. The home consists of a 2-storey older traditional building with a modern, in character, extension on the ground floor. There are 21 single bedrooms (11 of which have en-suite facilities) and 3 double bedrooms. There is a passenger lift. The home has pleasant, wellmaintained gardens that are easily accessible for services users. Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. The primary method of inspection was ‘case tracking’ which involved selecting 3 service users and tracking the care they receive through meeting with the service users, a review of their records, discussions with the care staff and observation of care practices. The Inspector visited during the early morning to observe practices by staff and to meet with service users. Some service users have dementia conditions and thereby communication for some is difficult. Establishing Service Users choices and informed decisions is dependant to some extent upon the consistency of staff, service users relationships with staff, and the quality of communication. Feedback obtained from Service Users in this report was in part through observations of their relationships with staff, and also through interpretations of their general levels of happiness with their routines. The Inspector spent an hour preparing for the inspection and five and a half hours in the home. There were no Comment cards or self-assessment form from the home available at this inspection. What the service does well: What has improved since the last inspection? Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 6 Some redecoration has been undertaken since the last inspection, the main dining room in particular has been improved by this. The Registered Manager has introduced some monitoring systems, for example a regular review of accidents, which should lead to improvements in care. 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. Oxendon House DS0000040280.V261057.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 Oxendon House DS0000040280.V261057.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): This area was not reviewed at this inspection. EVIDENCE: Oxendon House DS0000040280.V261057.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, 8,9,10 Service Users care needs are not always fully met. EVIDENCE: Care plans do not always detail Service Users care needs sufficiently clearly to ensure that staff are aware and responsive to individual need. For example staff were not aware of an instruction by the District Nurse to enable a Service User to keep her legs elevated. A Service User informed the Inspector that she was not aware of her care plan and there was no written evidence to show that she had been properly involved and consulted. One Service Users moving and handling assessment had not been fully reviewed and updated, and did not contain sufficient detailed information for staff to be able to deliver care consistently. Staff have not always had the training to support the delivery of Service Users healthcare needs. For example, a request by a Service Users General Practitioner to check a Service Users pulse rate if a particular situation arose, Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 10 had not been actioned through ensuring that all staff were trained and competent in doing this. The procedure is not one normally expected of staff in a care home, but before accepting the responsibility of the instruction from the General Practitioner, training should have been given. The wording by staff in records of health care is sometimes ambiguous, and needs clarification. It was evident from observations of staff during their duties that they are aware of the expectation that they preserve service users rights, privacy and dignity, and interviews with service users also confirmed that this was occurring. The administration of medications was observed and a breech in hygiene discussed with the staff member. The Inspector observed that two prescribed medications in the medication trolley were not clearly labelled, due to labels being torn, and thereby did not identify the person for whom they had been prescribed. Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 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): 12,15 Service Users needs were generally well met in this area. EVIDENCE: Service Users expressed general satisfaction with their lifestyles. There is a regular programme of relevant activities and senior staff specialize in providing these. Records are kept of Service User involvement. Service Users who wish to have a morning paper were provided with this and it was clear that individual needs are recognized and responded to. There was a shortfall in the provision of a suitable diet to one Service User as the instructions from the dietician had not been properly highlighted on the care plan and were thought by the cook to be historical and not current. However Service Users felt the food provision was appetizing and of good quality. Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 12 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, The complaints process needs to be understood by all staff. EVIDENCE: The senior on duty at the time of the inspection was not aware of the complaints record and it was therefore not reviewed at this inspection. Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 13 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): 26 The home was clean and comfortable, providing a homely environment for Service Users. EVIDENCE: Areas of the home were sample checked and found to be clean and comfortable. Decoration is ongoing and the well-maintained garden area with bird table is pleasant to look out on from the lounge, dining room and some bedrooms, and for Service Users to enjoy in good weather. Oxendon House DS0000040280.V261057.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): 28,29,30 Service Users were seen to be in safe hands, but Staff need further training in some areas. EVIDENCE: Service Users needs were being properly met by staff at the time of the inspection. When the Inspector arrived there were two night staff on duty who confirmed that they were fully able to cope with Service Users needs at night times and that they had enabled a Service User who was unable to sleep during the night, to rest comfortably downstairs. Although the Registered Manager was going on a course during the day she came in early to support the morning shift, to assist in shift planning and to ensure a good “handover” was given. There are good recruitment processes and induction training at the home but there is a need for further input on training, especially in relation to Dementia care. The staff-training plan was not seen at this inspection, as the Registered Manager was not available. Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 15 Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 16 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): 31,35,38 At the last inspection Inspectors found that there were insufficient experienced staff employed to properly support the Registered Manager, and to free her up to fully undertake her managerial duties; and that the ratio of senior staff needed to be improved. Whilst there has been some progress in these areas there is still a need to secure a strong senior team. EVIDENCE: The Registered Manager has made some progress since the last inspection in fully complying with the standards and securing robust processes to ensure Service Users needs are properly met. Service Users speak highly of the commitment and caring natures of the Manager and staff, and there have been recent letters from relatives praising the care at the home. Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 17 The main areas identified at this inspection for improvement are: • The need for consistently detailed and up to date care plans that highlight Service Users needs and the ways in which these are to be met. Improvements were evident in some care plans but there are still shortfalls that have compromised the quality of care delivery for some Service Users. • Staff need to be properly trained to meet Service Users needs, and there must be sufficient fully trained and competent Seniors to enable the Registered Manager to delegate some areas of responsibility. Some Service Users who are mentally frail are not receiving their personal allowances and their choices are thereby restricted. Advice was given on the need to establish Service Users financial arrangements for receiving their personal allowances at the time of their admission. Risk recognition and management need to be improved, especially in view of the home caring for some confused Service Users. The following shortfalls were noted at this inspection: • The non-secure storage of some products that could be hazardous e.g. Steradent tablets in a confused Service Users room. • The lack of observation or security of the “back entrance” to the premises in relation to Service Users with confusion. • The hazardous storage of equipment in a bathroom. • The lack of security in the sluice area despite a notice on the door that it must be kept locked. • The acknowledgement by a senior staff member that the medication cupboard was not always fully secured when medications were being delivered to Service Users. Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 18 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 2 9 2 10 3 11 x x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 x x x x x x x x 3 STAFFING Standard No Score 27 x 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x 2 x x 2 Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Timescale for action Service Users care plans must be 31/01/05 sufficiently detailed to support good care in all areas and must be reviewed and updated with appropriate regularity. Prescribed medicines must be 30/11/05 properly labelled to identify the Service User for whom they have been prescribed. Staff must receive training 31/01/05 appropriate to the work they are to perform. There must be sufficient trained 31/01/05 and experienced staff at the home to enable the Registered Manager to fully undertake her management duties. Individual training plans for staff 14/12/05 demonstrating how requirements 3 and 4 above are to be met must be forwarded to the inspector. Requirement 2 OP9 13 3 4 OP8OP30 OP30 18 18 5 OP3030 18 Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 20 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 OP8OP7 Good Practice Recommendations There should be greater emphasis on the accuracy, clarity and quality of records and the need for staff to date and sign documents. To this end further staff training and/or supervision may be required. There should be greater focus on risk management in relation to premises and storage issues, including those detailed in this report. Alternative diets served to Service Users because of special dietary need or choice should be recorded. All senior staff need to be familiar with the complaints procedure and the need to document complaints received from Service Users, relatives, visitors or staff themselves. To this end the complaints log should be available to them. Where Service Users are not receiving their personal allowances and there is no Power of Attorney set up, the Registered Manager should discuss the individual circumstances with the Care manager and relatives at the next review. 2 3 4 OP38OP9 OP15 OP16 5 OP35 Oxendon House DS0000040280.V261057.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Oxendon House DS0000040280.V261057.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. 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