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Care Home: Madley Park House

  • Madley Park Witney Oxon OX28 1AT
  • Tel: 01993890720
  • Fax: 01993890724

Madley Park is a care home providing personal care and accommodation for 60 older people. It is located on the outskirts of Witney in the centre of a housing estate and close to many amenities. The home is provided by The Orders of St John Care Trust. The accommodation is in semi-contained care wings that allow residents to relax in their own rooms, the lounge areas or the dining room. There is also a large central area on the ground floor known as `the heart of the home` that provides a friendly social area to residents for relaxing and entertainment. Attached to this area is a hairdressing salon serviced by a visiting hairdresser three times a week. There is also access to a pleasant, safe enclosed garden for residents and their visitors to enjoy. The current range of fees is between £665 and £750 per week.

  • Latitude: 51.794998168945
    Longitude: -1.4620000123978
  • Manager: Mrs Maureen Judson
  • Price p/w: £708
  • UK
  • Total Capacity: 60
  • Type: Care home only
  • Provider: Order of St John Care Trust
  • Ownership: Charity
  • Care Home ID: 10136
Residents Needs:
Dementia, Sensory impairment, Physical disability, Old age, not falling within any other category

Previous Inspections

This may not be the latest inspection for this service as we are having techinical problems updating from CQC - please check directly on the regulators website for the most recent report; bestcarehome hopes to be back to regular updates shortly.

For extracts, read the latest CQC inspection for Madley Park House.

CARE HOMES FOR OLDER PEOPLE Madley Park House Madley Park Witney Oxon OX28 1AT Lead Inspector Delia Styles Unannounced Inspection 28th April 2008 10:45 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 Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 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. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Madley Park House Address Madley Park Witney Oxon OX28 1AT 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) 01993 890720 01993 890724 manager.madleypark@osjctoxon.co.uk Order of St John Care Trust Patricia Just Care Home 60 Category(ies) of Dementia - over 65 years of age (30), Learning registration, with number disability over 65 years of age (3), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (60), Physical disability over 65 years of age (35), Sensory Impairment over 65 years of age (40), Terminally ill over 65 years of age (5) Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of residents accommodated at any one time should not exceed 60. 7th November 2006 Date of last inspection Brief Description of the Service: Madley Park is a care home providing personal care and accommodation for 60 older people. It is located on the outskirts of Witney in the centre of a housing estate and close to many amenities. The home is provided by The Orders of St John Care Trust. The accommodation is in semi-contained care wings that allow residents to relax in their own rooms, the lounge areas or the dining room. There is also a large central area on the ground floor known as the heart of the home’ that provides a friendly social area to residents for relaxing and entertainment. Attached to this area is a hairdressing salon serviced by a visiting hairdresser three times a week. There is also access to a pleasant, safe enclosed garden for residents and their visitors to enjoy. The current range of fees is between £665 and £750 per week. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is three star. This means the people who use this service experience excellent quality outcomes. This inspection of the service was an unannounced ‘Key Inspection’. A key inspection is one in which the ‘key’ National Minimum Standards (NMS) – those standards that the Commission considers to be the most important to residents’ well-being, are assessed. The inspection took place on a Monday and lasted about 6 hours. It was a thorough look at how well the service is doing. We took into account information that we have received about the service in the form of the homes Annual Quality Assurance Assessment (AQAA) and any other information that we have received about Madley Park since the last inspection. The AQAA is a self-assessment of how well the home feels they are meeting the standards of care for people living at the home. All registered homes and agencies must send us their AQAA each year. We asked the views of the people who use the service and other people seen during the inspection or who completed one of the questionnaires that the Commission had sent out. Of these, 9 residents’ “Have your say about Madley Park House” surveys were received by us in time to include peoples’ views in this report. The homes own quality audit report (November 2007) based on 50 completed questionnaires, was also taken into account. A tour of the home was undertaken and the inspector joined residents for lunch. A sample of residents’ care plans and records, medication records and staff recruitment files was looked at. This report summarises how well the home is meeting the NMS, through using the ‘Key Lines of Regulatory Assessment’ (KLORA). The KLORA sets out the sorts of evidence that best describes the standard - ‘excellent’, ‘good’, ‘adequate’ or ‘poor’ - of the care and facilities provided for people living at Madley Park. A judgement statement summarises each section (outcome group) in the report. The overall quality (‘star’) rating is arrived at through a ‘rules based’ approach, with the emphasis on three sections of the report that look at the safety and management of the home: Health and Personal Care, Complaints and Protection, and Management and Administration. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 6 We would like to thank all the residents and staff for their time and help during the inspection process. What the service does well: What has improved since the last inspection? Staff have had additional training in caring for people living with dementia and this has helped them to develop ‘person-centred’ care and improve communication with residents and their families about the best way to support and care for residents with poor memories. The way in which peoples care plans (the information about each resident’s care and support needs) are written is being improved, to make sure that each person’s likes and dislikes and the way they want to be supported and helped, is clearly set out for care staff to know what they need to do. Residents are being encouraged to be more involved in the running of the home – through joining the Health and Safety Committee, Amenity Committee for example – and taking part in the recruitment process for some staff. Communication with residents and families has improved with the introduction of a homes magazine and updating of news and events on the homes website. The Statement of Purpose and Residents’ guides have been updated so that people have better information about the home and facilities on offer. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 7 In response to a complaint, the home has improved the way it keeps in contact with families when a resident is in hospital. 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. The summary of this inspection report can be made available in other formats on request. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 does not apply, as the home does not provide intermediate care. Quality in this outcome area is good. Prospective residents and their representatives have the information they need to decide whether the home is likely to meet their needs. The personalised needs assessment mean that peoples individual needs are identified and are planned for before they move into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes Statement of Purpose and Service Users’ (Residents) Guide have recently been updated and improved. The Order of St John Care Trust website is also a good source of information about the services it runs and the Madley Park House Internet web page has also been expanded to give people ‘user friendly’ information and news about the home and facilities. Seven out of the eight residents who completed our surveys said that they felt they had had enough information about the home before they came to live there. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 10 The homes AQAA tells us that prospective residents and their families are always encouraged to come and look around the home prior to admission at any time and as often as they wish. This was the case on the day of the inspection when one person was spending time at the home, including joining in some activities in the morning and lunch with other residents. All residents have a full assessment of their care needs undertaken by either the home manager, Head of Care or a Care Leader before they are admitted. Assessments include the views of the resident, family member or representative and other professional health and social care workers. Overall, the sample of residents’ care records seen showed that the assessment process is satisfactory and that new residents are admitted for a trial period of four weeks so that both the resident and the home can decide whether Madley Park House can meet their assessed support and care needs. However, there appeared to be less information about the assessment of care needs for a person admitted for regular short-stay, ‘respite’ care. This was discussed with a Care Leader on duty who agreed that the assessment information for one such person, who has had previous short stays in the home, was not up to date, and there was insufficient information about their usual care, support and family contacts. Although staff said they knew this person’s care needs from previous admissions there is a potential risk that changes in the person’s condition since their last stay may not be identified and so they may not have the level of care they now require. Also, the home should ensure that the person’s admission and discharge arrangements (for example, transport and prescribed medications) are in place, and who (of the person’s family or representatives) to contact in an emergency. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. There is good communication between health and social care professionals on a regular basis so that the health needs of residents are well met. The staff have a good understanding of residents care needs, and care is offered in a way that promotes and protects residents privacy, dignity and independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection further work has been done to develop and improve the way in which residents’ health and care needs are set out in written plans of care. A sample of 4 residents care records was examined during the inspection. There was a range of completed risk assessments and measurement of peoples’ dependency (to show how much they could do for themselves and what staff would need to help them with). Risk assessments included topics like nutrition, falls, and developing pressure-related skin damage (‘pressure sores/ulcers’). Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 12 Although the care records are reviewed at least monthly, there is not always evidence that the staff have updated the care plans when a resident’s care needs have altered. For example, a resident who has difficulty in walking and needed equipment and two carers when they first came to the home, is now able to mobilise without staff aid within their room. The care plan had not been updated to show this. The care plans for a resident who has dementia did not show what sort of help and reassurance staff needed to give when this person becomes agitated and confused about where they are and if they become verbally aggressive to staff and other residents. Though in practice, it was clear that staff know the residents well, the care plans need to be more detailed and ‘person-centred’ to show that each individual’s care matches their assessed needs and is consistent (especially where residents are unable to tell staff about their care and what they want). Discussion took place with the manager and Head of Care about ways in which the staff should further improve the care records to detail the actions they carry out to meet each resident’s listed assessed care and support needs; and to include the residents’ views about how well their care needs have been met (evaluation of care). The homes own quality audit results for November 2007 about the topic of care, showed that over 60 (a total of 50 completed questionnaires) of residents felt their care is ‘excellent’ or ‘good’ (around 30 ). The responses to the Commissions surveys were similar: of the 9 surveys completed, 7 people said that they ‘always’ receive the care and support they need and 2 that this is ‘usually’ the case. Eight out of 9 people said that they ‘always’ had the medical attention they need. The homes survey (November 2007) showed least satisfaction with the ‘provision of medication’: though 64 thought it was ‘excellent’ and 25 ‘good’, a further 11 felt it was ‘adequate’. The home now involves residents in the review of their medication with the GP where possible. A spot check of the medication records (MAR) for 4 residents was undertaken. The medication systems within the home were found to be in good order overall, though some hand-written entries made by care staff (where a resident’s medication had been changed on the instruction of their GP) had not been checked and countersigned by a second staff member. This is a good practice recommendation to reduce the risk of mistakes being when altering the MAR charts to show changed dosage or timing of medicines that could result in a resident getting the wrong dose of a medicine. The homes AQAA tells us that staff authorised to give out medicines have all had training in safe administration of medicines and will be undertaking further training to the ‘level 2’ basic training. The chemist who supplies prescribed medicines to the home completes regular checks to make sure that storage Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 13 and records of administration of medicines are in order. The home also undertakes its own checks of the medication systems and staff safety and competence. There are no residents who currently are able, or want to, keep and administer their own medicines, but the home has policies and procedures that would allow them to do so if they wished. The home has good communication with district nurses and other health and social care professionals who may need to be involved in the care of residents during their stay. In discussion with residents and from information provided by surveys it was evident that residents do feel respected and their individuality is recognised and supported. In terms of staff respecting residents’ privacy and dignity, the homes own Resident Quality questionnaire (2007) responses showed that 62.5 felt this was ‘excellent’, 35 ‘good’ and 2.5 ‘adequate’. The responses to our recent survey confirmed this. Staff were seen to knock on residents’ bedroom doors and bathroom doors and waiting for a reply before going in. Residents all have a phone point in their room that can be used to plug the home’s mobile phone in to receive incoming calls in private. Many residents choose to have their own ‘land-line’ phone in their room. One resident commented on how they appreciated the ability to keep in contact with friends and relatives via their phone and from their visits. All staff are trained and supported in caring for people who are very ill and at the end of their lives. Written tributes to the home show that the sensitivity and care of residents and their families is of a high standard. One relative’s tribute, addressed to the manager and all the staff, summed this up: ‘Thanks for giving [our loved one] a beautiful home and for all the kindness shown to her by members of the staff. The kindness of the carers was something she always mentioned to me. We are particularly grateful that she could pass away peacefully in her own home, being so well cared for. Thank-you for making this possible’. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. There is a good range of activities within the home and wider community so that residents have opportunities to take part in stimulating and motivating activities that suit their abilities and interests. The meals are good and offer choice and variety and cater for residents special dietary needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a full-time activities coordinator and there is a full and varied activity programme that tries to meet the wide range of interests and abilities of the residents. On the day of this inspection the activities coordinator had a day off, but care staff helped with morning activities in the ground floor lounge – a knitting group. In the afternoon a regular volunteer who ‘calls’ for the popular Bingo session, led a busy session for residents. Other activities include a gardening club (residents had been busy planting up bedding and tomato plants ready for planting out), visits from outside entertainers, museum boxes (the focus for reminiscences about local life ‘in the old days’) and regular trips and outing to places of interest. The residents spoken with felt they had enough opportunities to be involved in activities and hobbies that suited them. One person said that they preferred to Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 15 stay in their own room and spend time as they wish – reading, doing crossword puzzles, writing to friends and relatives and receiving visitors. The homes own quality questionnaire (2007) showed that almost 70 of people thought that the organisation, variety, frequency and choice of activities are ‘excellent’ and the remaining 30 ‘good’. Survey responses to our more recent survey (9 questionnaires) showed a wider range of satisfaction – 3 people felt that there are ‘always’ activities that they can be involved in; 4 that this is ‘usually’ so, and 1 person only ‘sometimes’. The home manager has plans to improve the gardens and to provide more outdoor entertainments. In particular, the home would like to have its own minibus so that there would be transport to increase the number of outings and local trips on an ‘ad hoc’ basis when the weather is good. The catering in the home – variety and choice, presentation, quality, portion sizes, dining room presentation and ambience, mealtimes and availability of additional snacks and drinks – is a quality topic included in the homes own report (2007). About 58 of residents scored this as ‘excellent’; approximately 40 ‘good’ and the rest, ‘adequate’. The nine responses to the commissions survey showed that four people ‘always’ liked the meals, four people ‘usually’ and one person ‘sometimes’. The AQAA shows that the home has reintroduced its monthly ‘spot check’ of people’s satisfaction with the meals and that the manager and administrator are to complete catering audits. The inspector joined residents for lunch (12.30 pm) during the inspection. The meals looked and smelled appetising. Two people said that their portions were too large, but enjoyed what they could eat. Another said that they had ‘too much gravy’ that they did not like. There was a choice of dessert, and cream, custard or ice cream to go with it. Lunch was unhurried with time for conversation. We consider that some aspects of food service could be improved – for example food portions, sauces/gravy offered separately and more appropriately sized cutlery and seating/positioning of residents at the dining table – to add to residents’ individual choice and enjoyment of their meals. One person mentioned that sometimes their hot evening meal is served on a cold plate: the manager agreed that staff have had to be reminded to turn on the heated trolleys in time to make sure that hot food is served on hot plates. Residents are able to receive visitors at any reasonable time, and are able to entertain them in their own bedrooms or in the communal lounges. From what we saw on the day and residents and staff comments it is clear that staff always make visitors feel welcome. Again this was shown in the homes own survey results (2007) with the welcome from staff, refreshments and facilities Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 16 offered to visitors and communication with staff largely rated as ‘good’ or ‘excellent’. The spiritual and cultural needs of residents are well met within the home, with regular Holy Communion and visits from peoples’ own Christian denominations and arrangements to help people attend local places of worship if they are able. From the evidence seen and comments received, we consider that this home would be able to meet the needs of individuals of various religious, racial or cultural needs. It is evident from the homes AQAA and discussion with the manager and care leaders that a great deal of thought and consideration is given to how the home can meet residents’ needs in a ‘person-centred’ way and is committed to promoting equality and diversity for all the people who live and work here. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. The home has a satisfactory complaints system and the practices and procedures in place ensure that residents feel their views are listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The OSJCT complaints policy is clearly written and provides clear stages and timescales for investigation of complaints by the home and responses to complainants. The complaints policy is displayed on notice boards around the home and is included in the Satement of Purpose and Residents’ Guide. A summary of any complaints or compliments received is available in the home and updated each month. Residents and their representatives are made aware of the complaints procedure. Eight of the nine residents’ survey answers indicated that they know how to make a complaint. All of them felt that staff listened and acted on what they had to say. Feedback on all aspects of the service are encouraged and actively sought by the manager through regular review meetings with individual residents, their family member or representative, and the manager and care leaders. The AQAA tells us that the home has improved communication with residents and their families in a number of ways – for example, encouraging residents to raise any concerns at regular meetings or individually with the staff and the manager. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 18 One person described a particular concern that they had brought to the attention of the manager who had dealt with it promptly. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The homes own records showed that they have had 1 complaint in the last 12 months and this had been satisfactorily resolved. All the homes staff have had training about how to identify and report suspected abuse (Safeguarding of Vulnerable Adults). As part of their induction new care staff have training about safeguarding of adults that meets the Skills for Care standards. All new staff receive copies of the General Social Care Council (GSCC) Codes of Conduct that set out the standards expected of employers and employees involved in social care. All staff are also given a copy of the organisations ‘whistle-blowing’ policy that explains their responsibility to report any poor or abusive practices that they witness and the organisations comittment to support them to do this, in order to protect vulnerable people in their care. Regular updates in safeguarding issues are part of the ongoing training and development of staff. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 & 26 Quality in this outcome area is excellent. The standard of the environment within this home is excellent and provides residents with clean, attractive and comfortable accommodation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Madley Park House is purpose built and provides a light, spacious and attractive environment. The residents spoken with are very pleased with the home and their individual rooms, with en-suite facilities, and the privacy that these provide. Residents who were visited in their rooms had their own small pieces of furniture, ornaments and pictures that made their rooms cosy and personalised. The large ground floor communal area – the ‘Heart of the Home’ – is where much of the group activities and entertainments take place. There is a good choice of larger communal rooms and quiet sitting areas for people to use. Flower arrangements, plants, pictures, photos and artwork displayed around the home give it a bright and cheerful appearance. The standard of cleanliness Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 20 was commendably high in all areas of the home. There were no unpleasant odours. The manager has plans to improve the gardens now that the original planting scheme has matured, so that there will be more colour, sensory areas and a pergola with seating, to encourage more use of the gardens and outdoor space by residents. All staff have annual training in current infection control practices and are provided with individual hand sanitizers and protective clothing for use when carrying out personal care. A modern, well- equipped laundry room, with a separate laundry chute for transporting soiled laundry directly from the first floor to the ground floor, is well managed, clean and tidy. The systems for separation of soiled and clean laundry work are good and designed to reduce the risk of cross-contamination. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. There is a good match of well-qualified staff offering consistency of care to residents. The recruitment and training practices of the home are good, so that residents are safeguarded from potential risk from unsuitable or poorly trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Most of the people who completed our surveys think that the number, skills and experience of the staff meet the needs of the people living here. The home benefits from having a stable permanent staff team with relatively low staff turnover, so that residents get to know the staff and vice versa, and the home rarely needs to use agency staff. The staff rota showed that the numbers and mix of staff (senior and care staff) provide a good ratio of staff to residents. Residents spoken with said that generally there were enough staff on duty and they rarely had to wait for assistance if they needed it. Induction training for new care staff consists of ‘in-house’ induction, ‘elearning’ – working through a computer programme with assistance – and a day of OSJCT training, all to be completed within 6 weeks of employment. New care staff also ‘shadow’ an experienced member of the care team for as Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 22 long as necessary so that they are confident, safe and competent in their work with residents. The home benefits from being part of a large organisation that is committed to training and provides good training opportunities for all staff. The organisation also has an NVQ centre. Twenty-one of the 41 permanent care staff have achieved National Vocational Qualification (NVQ) in care at Level 2 and the senior staff hold or are working towards NVQ Level 3 in care. This means that the home has met the target of 50 of all care staff having achieved a National Vocational Qualification Level 2 or 3. All staff have attended a two-day training course about caring for people living with dementia; this has been very successful in helping staff to improve their understanding and consistency of care for residents with failing memory. A sample of 3 staff members’ files was looked at and showed that there are thorough systems in place for the recruitment and screening of new staff before employing them to work at the home. The AQAA confirmed that volunteers are also subject to Criminal Record Bureau (CRB) clearance. The manager said that she is hoping to increase the involvement of residents in the selection and recruitment of new staff, by inviting them to ask/suggest some of the questions put to applicants at interview and for their views about the suitability of prospective new staff after meeting and talking to them informally. This had already happened for the appointment of the Activity Coordinator and receptionists. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is excellent. The manager and senior staff provide good leadership to the staff team and are accessible to residents and their families. Residents views about how the home is run are actively sought and are acted upon so that the home operates in the best interests of the people who live here. The health, safety and welfare of the residents and staff is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is well qualified and experienced to manage the home. She has several years of senior management experience with Oxfordshire social services and the OSJCT and extensive experience of working in residential care settings for older people. She has the formal qualifications required for registered managers – NVQ Level 4 in Care and the Registered Manager’s award. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 24 There are clear lines of responsibility and accountability in place and staff spoken to felt that they were very well managed and the manager and head of care were approachable and helpful. Residents said that ‘all the staff in the offices downstairs [the manager, Head of Care, receptionists and administrator] are a very good’. The OSJCT has accreditation with an independent standards organisation (ISO9001) and Investors in People. In additon to audits from these organisations, Oxfordshire County council monitor the standards of care and facilities as part of its quality assurance for residents who are publicly funded. The OSJCT sends out a ‘Resident Quality Questionnaire’ each year. The questionnaires are analysed by the OSJCT Quality Assurance Manager who arrives at an overall quality rating for each of the care homes. The results of the questionnaires are set out in a report that is made available to the residents in the home. An action plan is drawn up by the home to follow up any specific problems or suggestions made in the questionnaires. Residents and their relatives are invited to discuss the questionnaire with the home manager or another person from OSJCT. The analysis of the 2007 Quality Questionnaires gave the overall ratings for Madley Park House as 70 ‘excellent’ and 30 ‘good’, with all respondents stating that ‘they would recommend an OSJCT Home’. Topics identified from the Quality Questionnaire as needing further attention were ‘Care, Catering and Gardens’ and it was seen that the manager has taken action accordingly. There are regular residents and relatives meetings that are advertised and residents can to add to the agendas. The manager has an ‘open door’ policy and residents are encouraged to discuss their views. The manager also goes around the home on a daily basis to chat with residents and listen to any concerns they may have. The home also has unannounced visits from a senior OSJCT manager (as required by us under Regulation 26 of the Care Standards Act 2000); and also from a manager/colleague from another OSJCT home. The OSJCT County surveyor and Catering Advisor also visit and provide monthly reports. This means that OSJCT carries out ‘spot’ checks to make sure that the standard of care and facilities for residents is being maintained. The homes Health and Safety policy and procedures are available to all staff and there is regular mandatory training and updates in fire safety, First Aid, care of substances hazardous to health (COSHH), moving and handling, food hygiene, and infection control. We discussed the management of residents’ personal allowances and the systems in place that ensure that residents’ are not at risk of financial abuse. Those residents who are no longer able or do not wish to, manage their own money have relatives or an appointed person to do this on their behalf. Each Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 25 resident (who chooses to) has a personal named account with a local high street bank. Small amounts of cash held in the home on residents’ behalf, can be made available to the resident on request to the care leader or administrator. The OSJCT and an external auditor audit the financial procedures so that residents’ are protected from financial mismanagement or abuse. There was evidence from conversation with staff, and from the homes staff training and supervision records, that the manager and staff put theory into practice so that residents can be confident in the safety arrangements in place in the home. The home has a Health and Safety committee, consisting of a Care Leader, Manager, Handyman, Care assistant and a resident, that meets to discuss procedures and any issues that arise. The OSJCT Health & Safety Manager is available for advice and support. Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 26 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 27 NO 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations * Ensure that the assessment and care needs of people admitted for short-stay (respite) care are sufficiently detailed and accurate, so that care staff can plan and provide care that safely meets the person’s current care needs. * Ensure that the care plans are sufficiently detailed about the actions staff need to take to meet the assessed care needs and goals of residents. Care plans should be evaluated and changed if necessary so that they remain relevant and up to date. If care staff have to hand write altered instructions to medication orders on residents’ MAR charts, on the verbal instructions of a doctor (General Practitioner), they should have a second care staff member check and counter-sign the amendment. 2. OP9 Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Madley Park House DS0000062634.V361221.R01.S.doc Version 5.2 Page 29 - 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!

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