Inspection on 07/12/07 for Oak Tree Mews

This is the latest available inspection report for this service, carried out on 7th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Oak Tree Mews 09/02/06

Oak Tree Mews 12/09/05

Oak Tree Mews 10/01/05

Oak Tree Mews 13/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Oak Tree Mews Hospital Road Moreton-in-marsh Glos GL56 0BL Lead Inspector Mr Adam Parker Key Unannounced Inspection 10:00 7th & 12th December 2007 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 Oak Tree Mews DS0000016517.V348688.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. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oak Tree Mews Address Hospital Road Moreton-in-marsh Glos GL56 0BL 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) 01608 650797 01608 652735 www.schealthcare.co.uk Southern Cross Healthcare Services Ltd Mrs Stephanie Julian Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd July 2007 Brief Description of the Service: Oak Tree Mews is a modern Cotswold stone family home, which has been extended and converted into a care home. It is located in a quiet no-through-road in close proximity to the High Street in the market town of Moreton-in-Marsh. The local hospital is within walking distance. The accommodation is on two floors, the ground floor having a number of bedrooms and the communal areas, which consist of a lounge/dining room and conservatory. On the first floor are the remaining bedrooms and a shaft lift providing access to this floor. Fifteen bedrooms have en-suite facilities. The remaining two have toilets adjacent. Eighteen bedrooms are for single occupancy, while the remaining room, although registered as a double, is used by one service user. There is easy access from the home to the large, welltended gardens, which have a number of parking spaces in front of the building. To the rear of the property there are open views to the countryside. The fees for this home start at £653.40 per week. Additional services not included in the fees include hairdressing, chiropody and newspapers. Copies of the homes Statement of Purpose and Service Users Guide are displayed in the main entrance to the home. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was carried out by one inspector over two days in December 2007. The registered manager of the home was present for the both days of the inspection visit, which consisted of a tour of the premises and examination of residents’ care files. In addition staff recruitment and training was looked at as well as documents relating to the management and safe running of the home. A sample of residents were selected for inspection against a number of outcome areas as a ‘case tracking’ exercise. During the inspection visit three residents were spoken to, to gain their views of the service. Survey forms were received from 13 residents, 13 relatives of residents and 3 from General practitioners (GPs). An Annual Quality Assurance Assessment (AQAA) form was completed by the home and forwarded to the Commission prior to the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: The home has a good system in place for assessing the needs of potential residents, planning their care and working to meet their health and personal care needs. A variable programme of activities is provided for residents suited to their preferences and visitors are welcomed to the home. The availability of the complaints procedure ensures that information is available should any complaint be raised by residents or on their behalf by relatives. In addition staff are trained in how to deal with any potential abuse issues. The home was generally well-maintained and clean providing residents with a safe and comfortable environment. A range of training is provided for staff and the recruitment is based upon robust procedures. The home is well managed and uses a quality assurance audit tool on a regular basis to check the standards of service provided in the home. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission procedure ensures that all residents are admitted on the basis of a full assessment of their needs, so that they can receive the care that they require. EVIDENCE: The assessment documentation for a number of residents recently admitted to the home was looked at. These had been completed following an assessment of the person’s needs recorded on a comprehensive pre-admission assessment document. This is carried out by the registered manager or on occasions a senior carer. In addition where residents had been discharged from hospital to the home, information had been obtained and a care plan from the funding authority had been received by the home for one person. It was noted that pre admission assessments had not been signed or dated by the person completing the document. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 9 The home does not provide intermediate care and so Standard 6 does not apply. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home works well to meet residents’ health and personal care needs whilst upholding their privacy and dignity. EVIDENCE: Care plans described specific needs and how these would be met through interventions. They had been reviewed on a monthly basis. It was reported that care plans were completed in conjunction with the resident and their relatives where appropriate and evidence was seen of this with the daughter of one resident signing the care plan. A daily record is maintained for each resident as well as a record of personal care given. Risk assessments had been completed for pressure areas, moving and handling, nutrition and falls. Risks are assessed pre-admission and then given further assessment when the person enters the home. The home uses a malnutrition screening tool and keeps a monthly record of weight. Both care Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 11 plans and risk assessments had been reviewed on a monthly basis and it was clear that where a need was identified through assessment, a care plan was written to manage this. There was recorded evidence of residents receiving input for health needs from visiting professionals such as district nurses GPs and physiotherapists. In several examples looked at the visiting professional had recorded details of the visit themselves in the resident’s record. Medication administration records (MAR) had no gaps in recording and any hand written entries had two staff signatures and had been dated. There were photographs of residents with the MAR charts as an aid to recognition as well as a space for recording any allergies which contained relevant information for one resident. A homely remedies policy was in place and a letter from a GP was seen regarding this. Storage temperatures for the refrigerator and the medication storage cupboard were being monitored and recorded and had had been maintained at the correct levels. Medication containers had been dated on opening as an indication to staff of the expiry date. A number of residents were self-medicating and medication care plans had been completed following risk assessment for these with locked facilities provided in the residents’ rooms. Staff administering medication have received training in safe handling procedures. Residents confirmed that staff knocked on doors before entering and were polite to them. Some rooms have been fitted with door knockers as an aid to privacy and dignity. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 12 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. This judgement has been made using available evidence including a visit to this service. Residents benefit from a varied activities programme, good social contact and a selection of meals planned through consultation about their preferences. EVIDENCE: The home has an activities coordinator and a range of activities are on offer to residents. Around time of the inspection visit a number of seasonal activities were taking place such as a pantomime, a Christmas party and a trip out of the home to view Christmas Lights in Stratford-on Avon. Notices about these were on display in the entrance hall of the home. Activities take place on each weekday afternoon in the lounge and these include playing scrabble, flower arranging and gentle exercises. In addition individual hand and foot massage is offered. A volunteer visits the home to entertain residents with piano playing. Minutes of residents’ meetings gave evidence of consultation regarding the activities programme. In the October meeting it was reported, “Residents are very happy with the activities now provided”. The home keeps a record of residents’ social interests and of any recreational activities that they take part in. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 13 Survey forms received from relatives of residents contained positive comments about how they were welcomed into the home when they visited. The home has a policy of allowing open visiting and visitors are able to have lunch. A number of residents are able to maintain their own links with the local community. The home is visited by the local vicar twice a month. A service with the vicar was being conducted during one day of the inspection visit and staff were inviting residents to attend. Information about advocacy services is available in the home. Residents are able to personalise their individual rooms with a number of items including furniture. The menu for the day was on display in the lounge area in a format suitable for viewing by people seated in the chairs. The home has a four weekly menu. Two choices of main course are given at lunch as well as two choices of dessert. In the afternoon tea and cakes are provided with a supper in the early evening with a choice of a cooked snack or sandwiches. A record is kept of any alternative meals provided to residents that are not part of the menu. It was noted that the dining area was attractively presented for lunch. On a survey form, one resident commented about the food “It’s nice it’s always hot.” When spoken to another resident felt that there was a lot of repetition with the meals. Another said that the home provided “good food.” Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 14 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available if any resident or their representative should wish to make a complaint and the home’s approach to training staff should ensure that residents are protected from abuse. EVIDENCE: The home has a register for recording complaints. The procedure for complaints is that on receipt, a letter is sent and following investigation a response is given within 28 days. The documentation and response to the one complaint received during 2007 was looked at. Information about how to make a complaint is available in the entrance to the home along with other information about the service. The majority of both residents and relatives who returned survey forms indicated that they knew how to make a complaint. The home has a policy for protecting residents from abuse as well as a ‘whistle blowing’ policy. Training in protecting residents from abuse has been given to the majority of staff employed in the home. The home has demonstrated that it will act to protect residents following an incident earlier in 2007 where appropriate referrals were made to protect the interests of residents. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 15 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): 19,21,24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the benefit of living in a well-maintained and clean, environment with personalised individual rooms. EVIDENCE: A tour of the premises was undertaken. All areas of the home inspected were found to be clean, well maintained and decorated and smelt fresh throughout. The communal lounge and dining area were particularly attractively presented. The entrance hall contained information about the home and about planned activities. There are well kept gardens to the rear of the home accessible through the dining area. At the front of the home there is a large garden with car parking. Some of the outside window sills were in need of repainting. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 16 It was noted that a communal toilet on the first floor did not have a hand washbasin. Consideration should be given improving this facility by installing one. Residents’ rooms were comfortable and contained various degrees of personalisation with some enjoying views of the countryside surrounding the rear of the home. The laundry had washable floor and wall surfaces and arrangements for hand washing. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 17 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff are deployed and training is undertaken in a number of areas to meet residents needs with robust recruitment practices in place. EVIDENCE: Staffing in the home is arranged so that on a typical weekday there are three carers on the morning shift with the registered manager, an activities organiser a cook and a cleaner. In the afternoon there are two carers and a cook and at night two carers. Based on information supplied during the inspection visit the home currently has 60 of staff trained to NVQ level 2 or above. One member of staff from overseas has had their qualifications verified to NVQ level. Records for recently recruited members of staff were examined. All the required information and documentation had been obtained including an employment history against which any gaps in employment could be explored. Checks against the Protection of Vulnerable Adults list were being made as well as with the Criminal Records Bureau. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 18 The home is currently working on implementing a new document for induction training that covers the common induction standards. Staff have received training in a number of areas relevant to the needs of people using the service, which include nutrition, care planning, dementia awareness, and the safe use of bed rails. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 19 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed with a variety of quality assurance audits in operation and safety checks to ensure that the home is run in the best interests of residents. EVIDENCE: The registered manager has a background in social care and has previous experience of managing a care home. She has achieved the registered managers award and is also an NVQ assessor and has recently attended fire safety training and has undergone a course to train other staff in moving and handling procedures. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 20 On a survey form one relative of a resident commented that the registered manager was “always friendly, warm, sympathetic and helpful”. There are a number of quality audits in place in the home as part of the overall quality assurance system. A validation audit is carried out on a monthly basis alternately done by the registered manager and the operations manager. Areas covered by the audit include such areas as accidents, complaints and medication. In addition unannounced visits are made to the home by the operations manager under regulation 26. Copies of reports of these visits are held in the home and were viewed during the inspection. The arrangements for looking after residents’ money was looked at and satisfactory arrangements were in place with records kept. A check on the money held for one person showed this to be accurate in relation to the records kept. Each resident had a clear plastic wallet, which was a useful way of checking the amount held. Secure storage is available in the home. Staff have received training in safe working practices in the areas of fire safety, infection control, food hygiene, moving and handling, first aid and health and safety. Weekly checks are made on hot water temperatures with records kept. Central heating boilers had been serviced during 2007. The electrical wiring in the home has been checked as well as portable electrical appliances. Work has been carried out in the home by an outside contractor in order to reduce any risk from Legionella. The home has completed a fire risk assessment although has not had a recent inspection from the fire safety officer. The kitchen has had an inspection from the environmental health department of the local authority and has retained its previously awarded three star rating. Cleaning materials were securely stored with no decanting from large to small containers evident. Staff have attended training in handling hazardous substances. Window restrictors are fitted to first floor windows although at the time of the inspection the home was awaiting the delivery of replacement restrictors. Although there have been no security problems with the home it is recommended that a security risk assessment should be completed for the premises. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 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 3 2 X 2 X X 3 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 3 X 3 X 3 X X 3 Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action No Requirements RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP3 OP19 OP21 OP38 Good Practice Recommendations Pre-admission assessments should be signed and dated by the person completing the assessment. Check all outside window sills and plan for these to be painted when weather allows. Give consideration to installing a hand washbasin in the communal toilet on the first floor. Complete a risk assessment exercise for the security of the premises. Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Oak Tree Mews DS0000016517.V348688.R01.S.doc Version 5.2 Page 24 - 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. 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