Care Home: Oxley Lodge

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What the care home does well What has improved since the last inspection? Improvements have been made to the carpets and floor coverings in several bedrooms and corridors. The home has continued with training and updates for staff. The Registered Manager has introduced formal supervision for staff, a new training programme and the key worker system of working. Medication practices have improved and more staff have received training in safe handling of medicines. A number of staff have completed their training in infection control, Dementia care, NVQ Level 2 and adult protection, and that will enable them to expand their knowledge and skills and enhance the care they give to the people who use the service. It was noticeable that there have been many improvements made to the environment of the home. A rolling programme of decoration and refurbishment has been implemented, and some of the communal areas and bedrooms have been redecorated and new floor covering and some items of furniture have been provided. What the care home could do better: CARE HOMES FOR OLDER PEOPLE Oxley Lodge 453 Stafford Road Oxley Wolverhampton West Midlands WV10 6RR Lead Inspector Bhag Jassal Unannounced Inspection 24th September 2008 09:00 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 Oxley Lodge DS0000071868.V371932.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. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oxley Lodge Address 453 Stafford Road Oxley Wolverhampton West Midlands WV10 6RR 01902 398 112 01902 398 112 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) Aplin Care Homes Ltd Julie Sankey Care Home 30 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (30) of places Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 30 Dementia over 65 years of age DE(E) 4 The maximum number of service users to be accommodated is 30 2. Date of last inspection Brief Description of the Service: Oxley Lodge – care home is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of 30 older people and 4 these people can be with Dementia care needs. The Registered Provider of Oxley Lodge is Aplin Care Homes Ltd. and the Registered Manager is Ms Julie Sankey. Oxley Lodge stands in its own extensive grounds facing on to the Stafford Road, the main entrance and road access to the home is via Oxley Moor Road. The bedrooms are single rooms, five of which have en suite facilities, all other bedrooms have a wash hand basin and toilets and bathrooms are located nearby. There is a passenger lift for access to the first floor. Oxley Lodge is located near to a bus route, shops and other amenities are nearby. People can obtain information about this service from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk At the time of this inspection the manager reports that the current weekly fee is £357.00 to £408.00 - the reader may wish to obtain more up to date information from the care home. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 5 Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use the service experience good quality outcomes. This unannounced inspection took place on the 24th September 2008. This unannounced visit started at 09:00 and lasted 9 hours and 30 minutes. The home had 29 places occupied and one resident was in hospital. The judgements made within this report are based upon information supplied by the home, from interviews with the Registered Manager, the staff and people who use the service and their relatives. During the course of inspection the assessment information and care plans were inspected for four people who use the service. Medication administration was checked. Staff records were seen to check staff rotas, recruitment procedures and training. Various documents were seen in order to check compliance with health and safety legislation. A tour of premises was also undertaken and observation of care practices and interaction between staff and people using the service was also completed. We looked at four files of people who use the service to enable us to monitor progress in meeting previous requirements. Discussions took place with several members of staff and over a dozen of people who use the service and four visiting relatives were spoken to throughout the day of inspection. Registered Manager – Ms Julie Sankey was present throughout the inspection process. The Deputy Manager was also present for part of inspection and assisted Ms Sankey in the inspection process. On this occasion all the key Standards of the National Minimum Standards were assessed – that is those areas of service delivery that are considered essential to the running of a care home. Regulation 37 Notifications, concerns and complaints against the home, Regulation 26 reports and Annual Quality Assurance Assessment (AQAA) received from the care home were also considered and discussed with the Registered Manager. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was sent to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all Registered Providers. It informs us about how Registered Providers are meeting outcomes for people using their service and is an opportunity for Registered Providers to share with us areas that they believe they are doing well. It is a legal requirement that the AQAA is completed. Oxley Lodge returned their completed AQAA to CSCI within the given timescale. Information within this Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 7 document demonstrates that the Registered Manager recognises the strengths and weaknesses within the service and is able to plan for improvement. The AQAA provided information to supplement the inspection. On the day of inspection, several On-site Surveys were completed by three visitors, one service user and three members of staff. The overall feedback was positive about the service. We wish to thank the Registered Manager, the staff, people using the service and their relatives for their assistance and co-operation on the day of inspection. What the service does well: Staff have a good understanding of the individual needs of the people living at the home and staff assess and plan care to take account of peoples’ likes/dislikes and preferences. Time spent observing staff working identified a staff group committed to ensuring people receive a good standard of care and staffing levels were appropriate for the people accommodated. The Registered Manager is focused on positive outcomes for people living at the home and leads and supports a staff team who share the same values. Training opportunities within the home are good which ensures that staff are appropriately skilled and competent to carry out the duties for which they are employed. Observation of a selection of several completed On-Site Surveys from relatives, staff and people living at the home shows a high amount of satisfaction with all areas of the home and the care provided. People can choose to participate in social activity and are encouraged to maintain contact with their family and friends. Oxley Lodge care home is registered for 30 older people, including four people with dementia care needs. The home makes every effort to provide individuals with good care to meet the assessed needs following a care plan. The home operates a key worker system and a staff supervision system is also in place. The home communicates well with the families/friends and representatives of people who use the service. People who use the service say that they are happy and content with living in this care home and are comfortable and satisfied with the care provided. The visiting relatives confirmed this to us on the day of inspection. The atmosphere within the home is relaxed, comfortable and friendly. There is friendly rapport between staff and the people who use the service. Meals are varied, balanced and well – presented to meet each individual’s needs, preferences, likes and requirements. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 8 Most of the people who use the service are satisfied with the care they received and they commented “the food is very good here and tasty”, “I am happy in this place” and “the staff are very good, caring and kind”, and “the manager is very good and she sorts things out for us”. The home has a training programme, which all members of staff will be involved in, and this is improving their knowledge and skills to meet the changing needs of people who use the service. On–site surveys were completed by two members of staff. One member of staff stated that “We provide a range of choices with food and offer activities to suit the needs of residents. We have good communication with families and service users, always listening and doing our best in meeting their needs”. What has improved since the last inspection? What they could do better: Parts of the environment require refurbishment and re-decoration. There is a need for a number of windows to be replaced, and now more windows are showing signs of needing repair or replacement. The flooring on one staircase needed attention-cracks in the flooring on the staircase were a potential trip hazard, for staff and visitors accessing this area – we understand that since the inspection this flooring has been replaced. The home should continue to improve the detail and quality of daily care recordings to reflect the care that is being provided. This is to ensure that each Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 9 person’s care needs are known and the actions essential to meet these needs are understood by everyone delivering the care in the home. Those members of staff who as yet have not received mandatory training in safe working practice topics – for example, first–aid, food hygiene, health and safety, fire safety, infection control, moving and handling, adult protection, Dementia care, safe handling of medication, and NVQ Level 2 must do so as a matter of priority. This training would enable staff to improve further their care practices, social care knowledge and skills. The Registered Individual and Registered Manager must ensure that all checks are up to date, such as those of portable electrical equipment and water temperatures, in order to promote the health and safety of residents and staff. In addition, all the requirements made recently by the Fire Safety Inspector must be complied with to ensure people using the service are safeguarded in the event of a fire. 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. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 10 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 Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 11 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, 3 and 6. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Oxley Lodge care home provides adequate information to people who may be using the service and their families to enable them to make decisions about whether or not they wish to live at the care home. People who will be using the service receive a needs assessment prior to admission to ensure that their needs will be met. But the current needs assessment format needs updating and amending to ensure that there is a full/comprehensive needs assessment available for all people with Dementia who will be using the service. The home’s Statement of Purpose and Service Users’ Guide also needs updating to reflect the recent changes in its registration and Care Homes Regulations 2001 (as amended). EVIDENCE: Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 12 Admissions are not made to the care home until an initial assessment has been undertaken. At present the Registered Manager visits and completes an initial assessment form for all people who use the service at their home or hospital prior to admission. There was evidence in the 4 files/care plans of people using the service that were seen which contained initial pre-admission assessments carried out by the home, and had needs assessments carried out by other relevant professionals. The Registered Manager stated that she will be revising and updating the needs assessment information to ensure that the staff in the home have full/comprehensive information on the needs of people who use the service. She also stated that all the risk assessments are undertaken and recorded. It was acknowledged by the Registered Manager that the home’s Statement of Purpose and Service Users’ Guide were in need of revision and updating to reflect the recent changes in its registration and also changes to the Care Homes Regulations 2001 (as amended). Observations and discussions with the people using the service, the Registered Manager, and staff on duty indicated that the home continues to meet the basic individual needs of all the older people, including those with dementia accommodated at the home in sensitive manner. It was noted from the staff training records that a majority of staff have received training in Dementia care. The Registered Manager stated that all members of staff who as yet have not received training in Dementia care will do so as a matter of priority in order to increase their awareness, knowledge and skills about the care needs of people using the service. The home does not provide a service for those assessed and referred solely for intermediate care, who require help to maximise their independence and return home. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 13 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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have individual plans of care, which ensure that their personal, healthcare and social needs can be met. Medication is administered and stored in a manner that safeguards everyone using the service. People who use the service are treated with respect and dignity and their right to privacy is understood and upheld. EVIDENCE: People who use the service undergo an assessment of their needs prior to admission to the care home. A Care Plan is produced, which is based on the assessment of needs. The home operates a good key worker system, which helps to ensure that the recommendations arising from the care plan reviews are implemented. Daily care records were seen and entries made by care staff could not always be cross-referenced to the care plans. The daily care (day and night) Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 14 recording formats were also examined and it was noted that the quality and detail of care recording needs further improvement. The Registered Manager stated that she will ensure that the staff are aware of the importance of including all the information regarding people who use the service and their well - being, and all the entries made by the staff are always to be crossreferenced to their care plans. The Registered Manager also stated that the revised and updated formats of care plans and daily care recordings will be implemented immediately; and the staff will be closely supervised and supported to make further improvements in daily care recordings as a matter of priority. Discussion with people who use the service showed that the home has a good ethos of involving them in all aspects of their life. The care plans that were read were adequately written and included an element of risk assessment. Information from the initial assessments had been written into plans of care. The care plans are reviewed on a monthly basis by senior staff. Care Plans demonstrated that the staff actively promoted the rights of people who use the service of access to the health services both within the home and the community. Appointments are planned or arrangements are made for professionals to visit frail people using the service. Whenever possible continuity of care for the service users’ declining state of health is assured. District Nurses are called upon to assist with clinical help, equipment and advice where necessary. The Registered Manager promotes the key worker system so that relationships between staff and individuals are enhanced. Visitors are able to meet people using the service in their bedrooms, in the lounge or in the visitors’ room on the ground floor. It was observed that people who use the service were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. We spoke at length with several people using the service and all of them commented positively about their care and felt they have everything that they need. Four people who use the service stated that “The carers are very good and kind and they look after us very well”. Two other people who use the service said “The carers are always there to help us”. Generally people who use the service appeared to be content and comfortable. They were complimentary regarding the quality of their lives and care they were receiving at Oxley Lodge care home. There are appropriate policies and procedures in place for the administration of medication. It was noted that the care plans contained a list of current medication. The Registered Manager stated that reviews are carried out on a regular basis of all the care plans to ensure that medication details are up to date. Appropriate records are kept of all medicines received, administered and leaving the home. Random sample of medication and administration sheets Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 15 were seen at the inspection and there were no discrepancies. All the medicines are stored in the medication cupboard and kept under lock and key. Daily checks are taken of the temperature of the medicines in the refrigerator and medication cupboard. There are controlled drugs used by one service user at the care home, which are stored securely and safely in a lockable metal cupboard in the medication cupboard. Medication rounds were observed during the inspection. Senior staff were seen to administer and record when medicines had been given. The Registered Manager stated that all senior staff responsible for administering medication were appropriately trained in safe handling of medication. However, the Registered Manager stated that those members of staff who are not yet trained to administer medication are due shortly to receive training in the safe handling of medication. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 16 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to exercise choice with regard to social and leisure activities at the home. Activities provided meet the needs of the people using the service. Relatives and friends are encouraged and assisted to maintain contact with the people using the service. The food at the home is of good quality and choices are always available. EVIDENCE: The home provides an activities programme in accordance with everyone using the service, their choices, preferences and capacities in relation to – social, leisure and cultural interests. People using the service, who were able to give opinion, were very complimentary about the activities provided, and particularly the external entertainers. People who use the service are enabled to enjoy a full and stimulating life style with a variety of options to choose from. A record of activities participated in is kept and photographs of major events displayed in the home. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 17 People using the service were seen sitting in the lounges chatting to staff and visiting relatives and in other communal areas within the home. Three people who use the service stated that they preferred to sometimes sit quietly in their bedrooms and the staff respected this. After lunch time a number of people who use the service were engaged in playing different games. Several people using the service spoken to stated that they were in regular contact with their family members and friends, and spoke about their visitors’ involvement and interest in their care matters. The visitors’ book kept in the home showed a considerable activity. People who use the service also keep contacts with the local community – for example, church services, pubs, shops and park. Five people who use the service told us that they are happy with the care and social activities offered by the care home. They further added “The home provides a good service and the staff are very caring and they are pleasant”. The home also provides a variety of indoor activities, including festive and birthday parties. The Registered Manager stated that the people who use the service were positively encouraged and helped to exercise their choices, and control over their lives and daily living, subject to risk assessments in terms of safety, security and capacity to make certain decisions. The Registered Manager also stated that a close liaison is maintained with the relatives and representatives, where the people using the service are not able to make certain decisions. The relatives of people using the service and their representatives are informed of the availability of Advocacy Service based at the local Age Concern. The information about the Advocacy Service is to be included in the home’s revised Statement of Purpose and Service Users’ Guide. Several people who use the service told us that “The home is very good and its peace and quiet here”. “The food is very nice, well cooked and tasty”. The consensus of people using the service was the range, quality and choice of food provided was very good and the home catered for those people using the service, who have individual preferences and medical needs. The Registered Manager stated that the menu is changed regularly in consultation with the people who use the service. This is usually done in accordance with seasonal changes as well. The kitchen is well equipped and kept clean and tidy. A new fridge, mobile hot food trolley and shelves have been provided and a new freezer has been ordered. At present the catering staff are not trained appropriately in food hygiene and food safety. However, the Registered Manager stated that they are due shortly to receive training in food safety and hygiene matters in October 2008. The broken fly screen on the back door is in need of repair/replacement and also there is a need to fit a fly screen to the kitchen window. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 18 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): 6 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is Complaints Procedure in place, a copy of which is made available to people who use the service and their relatives. This should ensure that any complaints made are listened to and acted upon. The home has an Adult Protection/safe guarding policy and procedure in place to protect people who use the service from all forms of abuse. EVIDENCE: The home has a good Complaints Procedure in place, which is referred to in the home’s Service Users’ Guide and in the Statement of Purpose. There is a system of recording concerns and complaints. The Commission for Social Care Inspection (CSCI) has not received any complaints about the care home or any adult protection/safeguarding referral since the last inspection. However, the Registered Manager stated that three complaints have been received and all were dealt with in accordance with the homes complaints procedure and two complaints were upheld and one was resolved satisfactorily. The people, who use the service, when asked, were certain of how to formally make a complaint but they said they would quite happily talk to one of the staff or the manager. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 19 The home has good policies and procedures in place regarding restraint, dealing with aggressive behaviour and prevention of abuse, which includes whistle-blowing policy. The Registered Manager stated that adult protection issues are discussed during induction training and supervision meetings. The Registered Manager stated that a number of staff have received formal training in protection/safeguarding of vulnerable adults and those who as yet have not received this mode of training will do so as a matter of priority. She also stated that trainers are being approached to set up this training. The AQAA completed by the Registered Manager states that Our plan for improvement in the next 12 months is to ensure that 100 of staff receive training in adults protection (POVA) and that the complaints procedure is followed. Several people who use the service stated they are satisfied with the service provision, feel safe and well supported by staff that have their protection and safety as a priority. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 20 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, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well maintained but needs some improvements to furniture, fittings and safety matters. The home is clean and hygienic. EVIDENCE: A tour of the premises highlighted a number of issues that must be addressed to the internal environment. The Registered Manager stated that there is a planned programme for maintenance with timescales for specific jobs, including redecoration of bedrooms and communal areas, and renewal of old furniture, fittings and floor covering. The two relatives commented about the décor within the home and stated that some areas would benefit from renewal. The hot water supply in all of bedrooms and bathrooms was tested and the hot water was found to be well above the recommended temperature level of close to 43°C. The hot water temperature varied from 48°C to 57°C in the bedrooms and 48°C to 50°C in the bathrooms. The above issue was discussed with the Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 21 Registered Manager and she urgently made contact with the Provider who agreed to call out a plumber the next day of inspection and to take appropriate action to rectify the inconsistent hot water supply in the home. The Registered Manager stated that she will ensure that the people using the service enjoy a regular and safe supply of hot water at the recommended temperature level of close to 43°C without the risk to people using the service of harm or scalding. Communal lounges have been re-floored with laminate flooring and a new carpet has been fitted throughout the lobby, ground floor and first floor corridors. The Registered Manager stated that the suitable floor covering and items of furniture and fittings are to be provided in several bedrooms as part of the rolling programme of redecoration and refurbishment. The majority of bedrooms are in need of the provision of suitable lockable facility for safe keeping of money and/or valuables for the use of the people living at the home. The self-closure mechanisms fitted on several bedrooms and communal area doors were in need of checking and adjusting to ensure that they close properly to their rebate in the event of fire to ensure safety of people using the service. Broken overhead lights in several bedrooms needs repairing/replacing appropriately. There were several bedrooms and communal areas where fused light bulbs in the overhead lights need replacing in order to ensure safety for people who use the service. The extractor fans in the WCs, bathrooms and bedroom en-suite facilities on both floors were not in working order and need repairing/replacing appropriately. There are a number of bedrooms without suitable tables to sit at for people using the service. One of the bathrooms was out of order and in need of urgent repair/replacement to ensure its use by people who use the service. There are no handrails fitted in the corridors for the use of people using the service. The handrails must be provided to ensure the safety and independence of people who use the service. The Registered Providers need to take appropriate action to address the above issues to ensure comfortable and safe environment at all times for the people who use the service. The AQAA received from the care home states that Due to the state of the home a complete re-vamp and redecoration has commenced to bring it up to standard. New equipment are being purchased, including correct equipment for the safe moving and handling of service users. We have employed a landscape contractor to maintain the grounds. Staff have attended infection control training, which has included all staff not just care staff. We have also managed to obtain further training for domestic staff in NVQ Level 2 in housekeeping and NVQ Level 3 in catering for kitchen staff. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 22 The AQAA also says “Our plans for improvement in the next 12 months are – to continue the re-vamp and purchasing of new equipment to ensure a good standard, which is safe, friendly and clean”. The home was found to be clean, tidy and free from any unpleasant odour. The Registered Manager stated that the floor covering in the bedrooms are being replaced as rolling programme. The home has good policies and procedures regarding infection control. It was also noted from the staff training records that a majority of staff have received training in infection control. The Registered Manager stated that those members of staff who as yet have not received this mode of training will do so as a matter of priority. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 23 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. This judgement has been made using available evidence including a visit to this service. Oxley Lodge care home is staffed by well-trained and experienced staff to meet the needs of people who use the service. There are good recruitment procedures in place to protect people who use the service. There is a good training programme in place that ensures staff are competent to do their jobs. New members of receive structured induction training. EVIDENCE: Information provided by the home and available staff rotas for the month of September 2008 indicated that the home has sufficient care staff to meet the needs of the 29 people using the service at present. There is deputy manager, a senior carer and three carers on duty in the morning shift, and deputy manager or a senior carer and three carers in the afternoon shift. Two carers are on wakeful night duty and a senior carer on - call in case of emergency. In addition to above, there are currently adequate numbers of ancillary staff on duty to cover catering, cleaning and laundry at the care home. The Registered Manager’s hours are supernumerary. All members of staff have either completed or are undertaking their relevant national vocational qualification (NVQ2 Care) and a number of other staff are now completing a higher level NVQ. The home does not employ Agency staff. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 24 The staff team is a well-balanced group in terms of age, experience, gender and ethnicity. 4 staff files were examined in detail in order to check compliance with the recruitment requirements. All four files contained copies of two written references, and a full employment history. There was evidence on staff files that all four had been subject to satisfactory Criminal Records Bureau (CRB) and POVA checks prior to being appointed. There was evidence on files that staff have received the statements of their terms and conditions of employment. The homes AQAA states what the following has improved in the last 12 months:• Implemented regular supervisions, which includes observation supervisions, and team meetings. • Employed new staff with a mix of qualifications and experience. • Extra staff is put onto duty to support activities and outings or when the service users needs it. • A laundry person has been appointed. The homes plans for improvement in the next 12 months are to:• Continue to develop the staff roles. • Implement staff appraisals and further training for all staff. There is a staff training and development programme in place. In addition to the mandatory training (see NMS OP38), staff also would benefit from training in adult protection/safeguarding issues, Mental Capacity Act 2005, equality and diversity, and physical aggression/challenging behaviours. Staff confirmed that training is provided and there are many opportunities to improve themselves for the benefit of the care of people using the service. All new staff received their induction training in accordance with the Skills for Care standards and specifications. One visitor stated in the On-Site Survey that Very pleased with the service provided by Oxley Lodge – All areas are excellent – the staff, the care, the personal touch they give the residents and their relatives. People who use the service commented that they feel safe with staff caring for them and they felt that the home employs people that are capable of carrying out their care duties. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 25 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, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is developing systems that monitor practice and compliance with plans, policies and procedures of the home and is aware of the need to keep up to date with practice and continuously develop management skills. Financial interests of people who use the service are safeguarded. The home promotes the health, safety and welfare of people using the service, but needs some further improvements. EVIDENCE: The AQAA received in September 2008 from Oxley Lodge showed that some improvements have been made in the environment of the home, care practices and staff training opportunities. The home has also improved interaction with Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 26 service users and involving them in their care plans and listening to what they want and listening to comments and suggestions made to the home. The Registered Manager – Julie Sankey has completed her RMA qualification and she is to undertake her NVQ Level 4 in care in due course. There are clear lines of responsibility and accountability within the home and the Registered Manager is well supported by the Registered Individual. The home has a formal staff supervision system in place and now this is being implemented. It was seen from the staff supervision records that all members of staff have received their regular supervision from the Registered Manager. Observations made and discussions held with people who use the service and their relatives and staff have indicated that the Registered Manager is very approachable and she operates an “open” door policy. People who use the service, who could express themselves stated that they are happy to approach the Manager and staff with any problems they might have and were confident that they would respond to them appropriately. Equality and diversity for service users was seen to be promoted throughout the home within the assessments, care plans, menus, and activities. Equality for staff is promoted through the opportunities for training at all levels. It was noted that the home has a Quality Assurance monitoring system in place. The service users questionnaires were distributed and received back in July/August 2008 and an analysis report on the feedback on the quality of services provided by the home has been prepared and made available in the home and a copy was seen by us, which appeared to be satisfactory. The overall feedback from people who use the service was positive. However, the home also needs to obtain feedback from other stakeholders and visitors to the home and analyse their responses as well. In addition, the Registered Manager should consider developing systems for determining the views of people using the service with Dementia/mental health needs, who are unable to verbalise their needs. Financial records and administrative procedures relating to the handling of monies of four people who use the service were inspected and were found to be well ordered and maintained. However, the Registered Manager stated that she will ensure that all the receipts of incoming and outgoing expenditure will be kept together and appropriately numbered. All the money belonging to people who use the service is kept in a safe and under lock and key. Only the Registered Manager and her Deputy Manager have access to the safe in the home. The home has good health and safety policy and procedures, and staff are aware of their responsibilities regarding these issues and a majority of staff Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 27 have received training in these issues. All safety systems and equipment are regularly checked and well maintained and records of all tests/checks are kept up to date. The tests on hoists in the bathrooms, and mobile hoists in the home, passenger lift and wheelchairs are undertaken on a regular basis to ensure the safety of people using the services in the home. The fire alarm system and emergency lighting system were tested on 12th September 2008. The staff call system, Fire Alarm and Emergency Lighting Systems were serviced on 20th September 2008. The hot water system has not been tested for Legionella and the Registered Manager stated that this will be done shortly. The records showed that the gas boiler was checked/serviced by a CORGI qualified engineer on 9th June 2008. The PAT testing had been not been carried out, which was due to be undertaken on 24th May 2008. The temperature of hot water supply in the home has not been tested since 29th August 2008. However, our tests on the afternoon of the day of inspection showed inconsistent supply of hot water in the home. The hot water temperature in the bedroom sinks and bathrooms measured between 48°C to 57°C. In order to ensure safety of people who use the service this deficiency was to be addressed promptly by the Registered Provider and the Manager on the next morning following our inspection of the home. The requirements made by the Fire Safety Inspector in his recent inspection report must be complied with to ensure people using the service are safeguarded in the event of a fire. The Registered Manager stated that she will follow up the other above issues immediately and make contacts with the Registered Provider and relevant contractors to undertake these works urgently. The staff undertake induction training in line with the “Skills for Care” format, which includes the basics in terms of fire safety, moving and handling, first aid, health and safety, infection control and working with hazardous substances. Further in depth training is accessed after induction through more formal course attendance and as evidenced by the home’s record for promoting access to national vocational qualifications. Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 28 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 2 2 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? NO 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 OP38 Regulation 23 (2)(j) Requirement The Registered Provider must take appropriate action to ensure a consistent supply of hot water at a safe temperature at all times. This is to ensure that people using the service enjoy a regular supply of hot water without the risk of scalding. Timescale for action 31/10/08 2. OP38 23 (4) The Registered Provider must 15/11/08 take appropriate action to ensure that the requirements made by the Fire Safety Inspector recently must be complied with to ensure people using the service are safeguarded in the event of a fire. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 30 1. OP1 The home’s Statement of Purpose and Service Users’ Guide should be updated to reflect the home’s current registration and also in line with the recent changes to the Care Homes Regulations 2001 (as amended). The Registered Provider should take appropriate action to ensure that all staff receive training in adult protection and safeguarding issues, Dementia care, equality and diversity, Mental Capacity Act 2005, aggressive/challenging behaviours and mental health needs, in order to fully meet the needs of, people who use the service. The Registered Manager should develop systems for determining the views of people using the service who are unable to verbalise their needs. It is recommended that all bedrooms be provided with a suitable locking facility and suitable tables to sit at for the use of people who are living at the home. The Registered Manager should take appropriate action to ensure that all the Fire Safety and Health and Safety equipment, systems and mechanisms are regularly tested and serviced and maintained in working order at all times in accordance with the relevant Health and Safety and Fire Safety legislation. The Registered Provider must take appropriate action to obtain feedback from stakeholders and visitors to the home on the quality of services and facilities provided to people using the service, as part of the home’s Quality Assurance monitoring systems. 2. OP30 3. OP33 4. OP24 5. OP38 6. OP33 Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Oxley Lodge DS0000071868.V371932.R01.S.doc Version 5.2 Page 32 - 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. 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