Inspection on 02/06/05 for Oxford Grange

This inspection was carried out on 2nd June 2005.

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

Oxford Grange 13/02/07

Oxford Grange 11/11/05

Oxford Grange 18/01/05

Oxford Grange 27/09/04

Oxford Grange 13/07/04

Oxford Grange 29/03/04

Similar services:

Carentan House

Ravensworth Lodge

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

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

CARE HOMES FOR OLDER PEOPLE Oxford Grange 30 Oxford Road Dewsbury West Yorkshire WF13 4LL Lead Inspector Tracey South Lynda Jones Unannounced 2 June 2005 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. Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Oxford Grange Address 30 Oxford Road Dewsbury West Yorkshire WF13 4LL 01924 463029 01924 455442 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) Northfields Care Homes Ltd Mrs Beverley Dyrlaga Care home 47 Category(ies) of 47 x Old age - over 65 years and 9 x Dementia registration, with number over 65 years of places Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 18 January 2005 Brief Description of the Service: Oxford Grange is owned by Northfield Care Homes Ltd and provides 24 hour residential care for up to 47 service users. There is a separate 9 bedded unit within the home, which accommodates elderly mentally ill service users.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 J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an unannounced inspection carried out on Thursday 2nd June 2005. The inspection took place over 7 hours and was carried out by two regulatory inspectors from the CSCI. There were 37 residents living at the home on the day of the inspection. One resident was in hospital. Inspectors carried out a tour of the home including a number of resident’s bedrooms. Care plans, case files, rotas, personnel files and training records were examined during this inspection. Nine residents and two relatives were spoken to. The registered owner has submitted an application to the CSCI in order to alter the current category of registration. The home is currently registered to take 9 people with a mental illness. What the service does well: What has improved since the last inspection? The writing of care plans has improved. The needs of the residents are recorded as well as the action required by staff to ensure those needs are met. Daily reports contain details of how the person has spent their day. Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 Page 6 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 J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 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 standard(s) 3 Relevant information contained in the pre-admission assessment is not being used to form the basis of the initial care plan. EVIDENCE: The manager carries out pre-admission assessments prior to new residents being admitted to the home. The manager is reminded to date and sign her assessment upon completion. In most cases a community care assessment, written by the social worker, is also received in respect of that person. Whilst examining case files it was clear that the information contained in the assessments is not always used to form the basis of the initial care plan. It was noted in one case file that the social worker had provided specific details about the “routine”, likes and dislikes of the resident. None of this information had been recorded in the care plan and therefore staff were unaware of certain aspects of the resident’s care needs. The same resident had been identified as being at risk from placing objects in her mouth. This information was not recorded in sufficient detail in the care plan. A risk assessment had not been completed. Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 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 standard(s) 7 and 8 Progress has been made with care plans. The needs of residents are detailed including the action and support required by staff. EVIDENCE: Care plans are in place for each resident. As mentioned previously, information contained in pre-admission assessments must be made available to staff and included in the resident’s care plan. Care plans cover the health, welfare and social care needs of that person and the action required by staff to ensure those needs are met. The reviewing of care plans takes place although it is not always done on a monthly basis. Staff sign to say they have reviewed care plans although just how thoroughly this is done, is not entirely clear. For example, one case file contained information that a resident had been under close supervision by the diabetic nurse. The resident’s blood sugar levels were being closely monitored, by both district nursing staff and staff at the home. No reference of this was made in the care plan. The same resident had other health problems that had not been referred to in the care plan. Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 Page 10 There was evidence in some case files that reviews had taken place. The review involved the resident and their relatives. Feedback was that everyone was happy with the placement. Some concerns had been raised by one family and a further review held a month later confirmed that those concerns had been addressed. There was evidence in place to suggest that residents have access to health care services. Each person is registered with a local GP. Specialist services are accessed for those people who are suffering from different forms of mental illness. A number of residents receive support from the Continuing Care Team based as Dewsbury hospital. A number of health assessments are undertaken including nutritional assessments. The majority of residents are weighed on a regular basis. There was evidence that the weight of some residents had fluctuated. For example one person had gained 6kg in a period of seven weeks. Whilst the information had been recorded, there was no evidence of any further action taken. The manager did mention that the scales being used were inaccurate for a period of time but have since been calibrated. A number of health assessments are undertaken including nutritional assessments. The majority of residents are weighed on a regular basis. There was evidence that the weight of some service users had fluctuated. However, there was no evidence in place to suggest staff had monitored this. The manager did mention that the scales being used were inaccurate for a period of time but have since been calibrated. Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 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 standard(s) 12 Very little progress has been made to ensure stimulating activities are provided. EVIDENCE: Residents spoke of how there was very little to do during the day and they often felt bored. One relative said their mother just sits in the chair all day and doesn’t get any exercise at all. One resident spoke of how she is able to make her own choices about how she spends her day, including when she rises and retires for bed. Another resident was more than happy with life at the home. He felt well cared for by the staff and said the food was nice. A member of staff said that activities did not take place on a planned basis, it depended on what residents wanted to do on a day to day basis. The manager explained that within the next two months an activities programme is to be introduced. Activities will take place on 3 afternoons per week. The home is fortunate to have its own minibus and day trips are to be organised. There is also an outing to St Anne’s organised in September 2005. A garden party is scheduled to take place on 7th August 2005. Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 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 standard(s) 16 and 18 Complaints are handled in accordance with the home’s procedure. EVIDENCE: The details of one complaint was examined. The manager had responded to the complainant within the 28-day timescale. The manager confirmed that there is a copy of the Kirklees Adult Protection procedure available in the home. New starters have received induction training on adult protection issues. The adult protection training video has gone missing. The manager said it will be replaced. One member of staff was asked what they would do if an incident of abuse was reported to them. The staff member had a good understanding of what to do and the relevant people to inform. Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 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 standard(s) 19 and 26 The grounds to the home are well maintained. The secure garden provides a safe area for residents to enjoy the outdoors. Some work is required in relation to maintenance. Risk assessments need undertaking for hot water temperatures. EVIDENCE: The gardens to the front and rear of the home are well maintained. The secure garden to the rear of the home offers a safe place for residents on the EMI unit to sit outside. A programme of routine maintenance has recently been re-introduced. The manager explained how she will highlight areas in need of redecoration. This will then be discussed with the owner and timeslots for completion will be given. The manager explained that the environmental health officer visited the home in March 2005. Recommendations were made and the CSCI have requested a copy of the report. Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 Page 14 The home was clean and tidy. Unpleasant odours were noted in a couple of bedrooms. Every effort should be made to eliminate these. The hot water has not been risk assessed. In some bedrooms and toilets, the water was too hot to keep your hand under. The manager was advised of this during the inspection. A letter has been sent to the manager advising that all hot water temperatures are tested. The hot water temperatures must be regulated so that the water is delivered at 43 degrees centigrade. Not all toilets contained paper towels, liquid soap and toilet roll. One bathroom/shower room contained communal toiletries and hard soap. The laundry flooring needs either replacing or repairing. The split in the lino is a tripping hazard. The manager spoke of how a new laundry system is being introduced next week. All residents will be allocated their own bed linen, towels and flannels. Each resident will be allocated bed linen etc in accordance with their needs. Labels on drawers were noted in a number of bedrooms. The labels detailed the contents of the drawers such as “nightwear”, “underwear”. Unless the labels are at the request of the resident they must be removed immediately. Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 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 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 The procedures for recruiting staff are not thorough and do not provide the necessary protection to people living in the home. Good progress is being made with NVQ qualifications. Induction training is basic. EVIDENCE: The current staffing levels are set at: AM – 6 staff ) PM – 5 staff ) deployed over three floors NIGHTS – 3 staff ) Out of the above staffing levels, one person is designated to work on the EMI unit. The CSCI have had concerns in the past about the staffing levels on the EMI unit. The manager and owner feel that the unit is adequately staffed. The unit must be staffed at all times and at no time during the day should the unit be left unattended. Staff have been instructed to carry a “walkie talkie”, to summon additional staff if and when required. Relatives have spoken with the CSCI and have expressed concerns that the unit is left unattended and that staff do not carry a “walkie talkie” with them, instead they shout down the corridor for assistance. Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 Page 16 Staff are making good progress in achieving NVQ qualifications. The manager was able to provide evidence that staff have undertaken a number of training courses in the past 12 months. Induction training is basic. A new induction package is to be introduced. The new employee will have to demonstrate they are competent in all areas of care. The personnel files of four staff were examined. There was evidence that CRB checks are not being received prior to the person starting work. There was no evidence in place to suggest that a POVA first check had been completed. Not all files contained two written references. Three references received were addressed “To whom it may concern” and were not from the referees as detailed on the application form. Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 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 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) None EVIDENCE: Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 2 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 1 STAFFING Standard No Score 27 1 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x x x x Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 Page 19 Yes Are there any outstanding requirements from the last inspection? 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 3 Regulation 14 Requirement Information contained in preadmission assessments must form the basis of the initial care plan. Reviews of care plans must be completed thoroughly including all aspects of that persons care since the last review. The care plan must be amended as the needs of the resident change. Monitoring of residents health care needs must take place and include any action/support required. A programme of stimulating activities must be provided. The hot water temperatures must be regulated so that the water is delivered at 43 degrees centigrade. The laundry flooring is dangerous and must be repaired/replaced. All communal toilet and bathroom areas must contain paper towels, liquid soap and toilet roll. The EMI unit must not be left J51J01_s45070_Oxford Grange_v229032_020605.doc Timescale for action 2nd June 2005 and thereafter 2nd June 2005 and thereafter 2. 7 15 3. 8 12 2nd June 2005 and thereafter To be in place by 15th July 2005 9th June 2005 and thereafter 9th June 2005 2nd June 2005 and thereafter 2nd June Page 20 4. 12 17 5. 26 13 6. 7. 26 26 13 13 8. 27 18 Oxford Grange Version 1.30 9. 29 19 unattended. Staff must ensure they carry their walkie talkie with them. A CRB including a POVA check and two written references must be received prior to new staff starting work. Thorough recruitment procedures must be carried out in respect of all new staff (timescale of 18.1.05 not met). 2005 and thereafter 2nd June 2005 and thereafter 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. 6. 7. 8. 9. Refer to Standard 3 18 21 19 Good Practice Recommendations The manager should ensure that the pre-admission assessment is signed and dated upon completion. The missing adult protection training video should be replaced. Toilet and bathroom areas are in need of redecoration. Labels on drawers in bedrooms should be removed. - Oxford Grange J51J01_s45070_Oxford Grange_v229032_020605.doc Version 1.30 Page 21 Commission for Social Care Inspection 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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