CARE HOMES FOR OLDER PEOPLE
Oxford Grange 30 Oxford Road Dewsbury West Yorkshire WF13 4LL Lead Inspector
Tracey South Unannounced Inspection 11th November 2005 09:30 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 Oxford Grange DS0000045070.V254473.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. Oxford Grange DS0000045070.V254473.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Oxford Grange Address 30 Oxford Road Dewsbury West Yorkshire WF13 4LL 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) 01924 463029 01924 455442 Northfields Care Homes Ltd Mrs Beverley Dyrlaga Care Home 47 Category(ies) of Dementia - over 65 years of age (46), Old age, registration, with number not falling within any other category (10) of places Oxford Grange DS0000045070.V254473.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2nd June 2005 Brief Description of the Service: Oxford Grange is owned by Northfield Care Homes Ltd and provides care and accommodation for up to 46 people with dementia care needs. The home is situated in a Victorian detached house in its own grounds. There are three floors of accommodation and the main office for Northfield Care Homes Ltd is situated in the basement. There are two car parks and gardens to the front and rear side of the building. Oxford Grange is situated on Oxford Road, approximately one mile from the local town of Dewsbury and two miles from the town of Batley. The home is also within easy reach by public or private transport. Oxford Grange DS0000045070.V254473.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over six and half hours. Thirty-seven residents were living at the home on the day of the inspection. There are currently 6 vacant beds as all the bedrooms are now being used for single occupancy only. Documentation examined during the inspection included medication records, policies and procedures manual, care records and service certification. The home received an additional visit on 11th July 2005. The purpose of the visit was to investigate a complaint. The nature of the complaint was regarding the hygiene standards at the home. The outcome of the investigation was that the complaint was not upheld. The management arrangements at the home have recently changed and the proposed manager is Rachel Bedford supported by deputy manager Linda Blackburn. Five residents, 2 visitors, 5 staff and the district nurse were spoken to during the inspection. Their comments have been included within this report. What the service does well:
Those residents spoken to gave positive feedback about their life at Oxford Grange. They said the staff were kind and helpful and the food at the home was good. Residents looked well cared for. Staff were observed attending to residents in a caring manner. Visitors to the home said they were always made to feel welcome. One relative said they were 98 happy with the home. One visitor said she was always offered refreshments and if she wanted to have a meal she would be able to do so. The atmosphere at the home was relaxed and friendly. During the afternoon a group of residents had a sing a long in the library, which they appeared to thoroughly enjoy. Residents said they were able to choose how they spend their day. One resident spends the majority of her time in her own bedroom. When spoken to she said she preferred to be alone rather than in a group, she went onto say that she has always been a bit of a “loner” and the staff respect this. Staff acknowledge the importance of celebrating special events. One resident was celebrating her 103rd birthday on the day of the inspection. Family and
Oxford Grange DS0000045070.V254473.R01.S.doc Version 5.0 Page 6 friends had been invited to join in the birthday celebrations, which took place at the home. 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. Oxford Grange DS0000045070.V254473.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 Oxford Grange DS0000045070.V254473.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: Oxford Grange DS0000045070.V254473.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): 8, 9, 10. Staff are not following medication procedures consistently. The rights of residents are respected. EVIDENCE: District Nursing staff were visiting the home during the inspection. The nurses explained how they visit the home on a regular basis to provide nursing treatment to residents. Staff at the home make referrals direct to the district nursing team. The main problems identified are poor skin integrity. Specialist equipment is provided to those residents suffering from pressure sores as well as being used as a precautionary measure. The nurses feel they share a good working relationship with the staff at Oxford Grange. The home has its own medication policies and procedures in place. Medication records were examined and there were a number of signature omissions noted. The majority of omissions referred to night medication. The medication had been given but had not been signed for. In addition to this the medication stocks for one resident did not tally with the records held. Instructions were recorded on the medical records requesting the person’s pulse to be taken prior to the medication being administered. There was no evidence that this
Oxford Grange DS0000045070.V254473.R01.S.doc Version 5.0 Page 10 had been done. As the home no longer provides nursing care, and if care staff are expected take someone’s pulse before administering medication, they should be trained to do so. Or alternatively the district nursing staff should take over such responsibility. Staff were observed caring for people in a sensitive and respectful manner. Residents and visitors were particularly complimentary about one member of staff. They explained how caring and considerate this particular member of staff was and he was described as the “perfect gentleman”. He was also said to have a great deal of patience and understanding when dealing with residents. Oxford Grange DS0000045070.V254473.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, 13, 14, 15. Visitors are made to feel welcome at the home. Residents are able to make their own decisions about their life. Residents receive a balanced diet in pleasant surroundings. EVIDENCE: The visitor’s book confirmed that the home receives a number of visitors at various times of the day. Those visitors spoken to said they were made to feel welcome at the home. One visitor said she is always offered refreshments. There have also been occasions when she has been offered a meal. Another visitor said the staff are always friendly and polite. It was clear that relatives had been informed of the new management arrangements at the home as they were seen congratulating the new manager on her promotion. One resident was celebrating her 103rd birthday and a small family party was being held at the home. Residents explained that they are able to make their own choices about their life. They spoke of how they are able to get up when they wish and although most had a “bedtime” it was their choice as to when they went to bed. One
Oxford Grange DS0000045070.V254473.R01.S.doc Version 5.0 Page 12 resident spends the majority of her time in her room. When spoken to she explained how she prefers to stay in her room and enjoys her own company. She said she would like staff to spend time chatting to her, but realises they are busy. A requirement was made in the last inspection that a programme of stimulating activities must be provided. The manager explained that they have been unsuccessful in recruiting an activities co-ordinator but activities do take place on an ad-hoc basis. Plans to develop a more structured approach to providing activities are in place. Progress will be monitored as part of future inspections. A group of residents decided to have a “sing a long”. One resident played the piano whilst the rest of the group sang. It was a lovely atmosphere and quite moving to see those residents who have dementia and sometimes struggle to communicate, enjoying singing along. The session lasted for over an hour. Since the last inspection, the dining arrangements have been altered and a new dining room has been created. Previously the majority of residents ate their meals in their own easy chairs with an over-bed table in place, only 4 of 5 people actually ate their meals at the dining table. One of the smaller communal lounges has now been made into a dining area and the majority of residents were seen dining together. The meal being served was fish, either fried or poached with potatoes or chips and mushy peas. Dessert was sticky toffee pudding and custard. The meal looked attractive and feedback from residents was that it was a very tasty meal. Visitors confirmed that the meals provided are generally very good. Oxford Grange DS0000045070.V254473.R01.S.doc Version 5.0 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: Oxford Grange DS0000045070.V254473.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: Although the above standards were not assessed it was noted that redecoration work to the toilet and bathrooms areas has commenced. One toilet area on the ground floor near the previously known EMI unit has been tastefully decorated. The manager explained how she has requested the shower room to be redecorated and the carpet in the library is to be replaced. The 3 requirements made in relation to standard 26 in the last report have been completed. Oxford Grange DS0000045070.V254473.R01.S.doc Version 5.0 Page 15 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): None of the above standards were assessed on this occasion. EVIDENCE: Oxford Grange DS0000045070.V254473.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. There is currently no registered manager at the home. Residents’ financial interests are safeguarded. EVIDENCE: The registered manager for Oxford Grange has moved to another home within the Northfield Care group. The proposed manager is Ms Rachel Bedford. Ms Bedford has worked at the home for approximately 3 years and demonstrates a good knowledge of caring for older people. She is about to commence the Registered Manager’s Award and has already gained NVQ qualifications at level 2 and 3. An application to register Ms Bedford as manager at Oxford Grange will need to be submitted to the CSCI. Small amounts of monies are kept on behalf of residents. All transactions are recorded and receipts are kept, detailing where the money has been spent and
Oxford Grange DS0000045070.V254473.R01.S.doc Version 5.0 Page 17 on what. Three residents’ monies were checked all of which were found to be correct. There was a lot of confusion around where the service certificates, e.g. for the lift, were kept. The manager should ensure that such documentation is readily available for the purpose of inspection. There are two movement and handling facilitators within the Northfield Care group and care staff are trained in-house. There was no evidence in place of when the lifting equipment had last been tested. Although staff could remember a recent visit, they were unable to locate the work sheets. The staff could not recall whether or not the slings, used when hoisting people, had been serviced. There was no certification in place to determine when the lift had last been serviced. This issues need to be addressed. Two members of staff were observed transporting residents in wheelchairs without the footrests in place. This was pointed out to the manager during the inspection. There was no evidence of Legionella testing being carried out. COSHH assessments were in place. Fire safety checks are carried out on a weekly basis. The last recorded fire drill was on 4.8.05, 8 staff were in attendance. Accidents relating to residents and staff are reported and recorded appropriately. Whilst examining the accident book it was noted that one resident had fallen on 4 occasions over a 2-week period. The resident’s case file was subsequently checked to ascertain whether appropriate safety measures had been put into place. The risk assessment was last reviewed on 25.8.05. The 4 falls had taken place during October 2005. There was no mention of these within the risk assessment. Staff need to be more vigilant and monitor residents’ mobility and other risk areas more closely. There must be evidence in place that appropriate measures have been put into place when residents are identified as being at risk. Oxford Grange DS0000045070.V254473.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 X 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X 1 Oxford Grange DS0000045070.V254473.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 Requirement Care plans must be amended as the needs of the residents change. Care plans must be reviewed at least monthly. Brought forward from the last inspection report dated 2nd June 2005. Staff must follow medication policies and procedures. Staff must sign for all medication contemporaneously. Proper arrangements must be made regarding the person who requires their pulse checking prior to medication being administered. Service certification must be available for the purpose of inspection. The date of when the passenger lift was last serviced must be forwarded to the CSCI. Risk assessments must be reviewed regularly (preferably monthly). Amendments must be made immediately as the needs
DS0000045070.V254473.R01.S.doc Timescale for action 11/11/05 2 OP9 13 11/11/05 3 OP9 13 11/11/05 4 OP38 23 30/11/05 5 OP38 13 11/11/05 Oxford Grange Version 5.0 Page 20 of the resident change. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP12 OP31 OP38 OP38 OP38 Good Practice Recommendations Progress should continue in ensuring a stimulating programme of activities is provided to residents. An application to register the proposed manager should be submitted to the CSCI. The manager should ensure that slings, used when hoisting people, are tested every 6 months. The manager needs to provide evidence that Legionella testing has been carried out. When staff are transporting residents in wheelchairs they should ensure that the footrests are in use. Oxford Grange DS0000045070.V254473.R01.S.doc Version 5.0 Page 21 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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