Inspection on 06/06/05 for Oak House

This inspection was carried out on 6th June 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Oak House 11/09/07

Oak House 17/04/07

Oak House 30/10/06

Oak House 02/11/05

Oak House 20/12/04

Oak House 08/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Oak House 19 Queens Road Weybridge Surrey KT13 9UE Lead Inspector Miss Marianne Barham Announced Inspection 06 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Oak House Address 19 Queens Road, Weybridge, Surrey. KT13 9UE 01932 857952 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Dr Ajit Prasad To be confirmed CRH (PC) 16 Category(ies) of Old age, not falling within any other category registration, with number (OP) 16. of places Dementia - over 65 years of age (DE(E)) 3. Dementia (DE) 1. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The age range of the persons to be accommodated will be over 65 years of age with the exception of one resident aged 60 - 65 years. Of the 16 service users accommodated 3 may be within the category DE(E). Of the 16 service users accommodated 1 may be within the category DE. Date of last inspection 20 December 2004 Brief Description of the Service: Oak House is a large detatched property situated within walking distance of Weybridge town centre. The home provides accommodation and care for up to 16 older people, 3 of whom may also have dementia. There are currently 14 service users living in the home. The home has a large TV lounge, a smaller quiet lounge and a separate spacious dining room. All bedrooms are single occupancy and are arranged over two floors, all except one have en-suite facilities. Bathrooms are situated on the ground and first floor and both have a chair hoist fitted. There is also a further toilet on the ground floor. The first floor may be reached by passenger lift or stairs. The home has a good sized, enclosed and well maintained rear garden that is accessible to the service users. The home has its own mini-bus, used to facilitate service users activities, and ample parking to the front of the building. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out at 10.10am by Marianne Barham, lead inspector for the service. The inspection was undertaken over a period of four and a half hours and was the first inspection in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The manager Yvonne Connock, who is not yet registered with CSCI, and the senior manager Kalem Choda were both present throughout the inspection. A total of eight service users and four members of staff were spoken with during this inspection. Records relating to the care of service users and management of the home were examined. There was a calm atmosphere in the home and service users appeared to be relaxed and well cared for. What the service does well: What has improved since the last inspection? The manager has recently introduced a new system of care planning that is more detailed and easier to understand than the previous system, making sure that service users receive the right support at the right time. The service users guide and statement of purpose has been updated to include details of the lead inspector and the CSCI local office address, meeting a requirement made at the last inspection. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 3 Service users are given enough information to make a choice about where they Live, and are not admitted to the home without a full assessment of their needs being undertaken. EVIDENCE: The home has a comprehensive combined service users guide and statement of purpose that gives clear information to service users of the services provided. All service users in the home have been supplied with a copy of the guide. A requirement was made at the previous inspection on 20th December 2004 that the guide be updated to reflect the change to CSCI from NCSC. It was pleasing to see that this had been done and also the lead inspectors name put in as well. When new service users are admitted to the home the manager would go out to either there own home or hospital as appropriate to assess their needs. The home has its own assessment package that is used in consultation with care managers and other involved professionals, as well as the service user and their family. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 9 The manager stated that where possible, service users are invited to stay at the home for a few days to a week so that both parties can be sure the placement is suitable. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 10 and 11 Service users are treated with dignity and respect at the home. They all have an individual plan of care detailing their health, personal and social needs. In the event of their death, service users and their families can be sure that they will be treated with sensitivity and respect. EVIDENCE: Care plans are generated from the initial assessment in consultation with the service user, their family and any involved professionals. The manager has recently updated all of the care plans on to a new format. The plans examined give clear and detailed information on all aspects of the individuals needs. The care plans had not been signed by the service users, or a representative and recommendation has been made to address this. Members of staff were observed throughout the inspection to interact in a respectful and positive way with service users. Training is given to all staff on the importance of promoting service users independence and protecting their right to privacy and dignity when carrying out personal care. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 11 The home has a detailed policy in place for care of the dying service user and also a policy and procedure for death of the service user. Staff members are made aware of these policies at induction and through supervision sessions. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 14 Service users experience a lifestyle in the home that is based on their individual needs and preferences. They are supported to exercise their right to choice and control in their lives. Contact with family, friends and the local community is maintained. EVIDENCE: The home has a four weekly programme of activities that is devised in consultation with the service users and the assessment of their individual needs. Activities on offer include bingo, music and relaxation, arts and crafts, reminiscence sessions using photographs and dominos. The home also employs outside entertainers for music and dancing, pantomimes and a visiting farm animal service. A key worker system is in place at the home and service users have one to one time with their key worker with activities chosen by the service user. The local community is also accessed for shopping, trips to the pub etc. Service users spoken with said they enjoyed the activities and were able to choose what they did and when. Service users are supported to attend religious services if they wish. The manager finds out as much as possible about a service user’s religious or cultural needs prior to admission in order to support them appropriately. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 13 Service users can receive visitors at any time, although they are asked to phone beforehand after 20.00pm. Visitors can see service users in their rooms or in one of the lounges or dining room. Service users are able to get up and go to bed when they wish, choose what activities to take part in and how to spend their time. Each service user has a ‘Key worker’ time every two months where they discuss any issues with their key worker, this is then fed back to the manager and acted upon as appropriate. Meetings for service users are held twice a year and recorded, however there is no system in place to show the outcome of issues raised. A recommendation has been made to address this. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 17 and 18 Service users legal rights are upheld in the home and they are protected from abuse. EVIDENCE: All service users are registered on the electoral roll and are supported to take part in the civic process if they wish. The home has a comprehensive policy and procedure on the protection of vulnerable adults from abuse that is in line with the Surrey Multi-agency Procedures. There is also a clear whistle blowing policy in place. All staff are made aware of these policies at induction and through supervision. All staff at the home had received in house training on adult protection procedures and those spoken with were aware of their responsibilities in this area. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24 and 26 Service users live in a safe and pleasant environment that is well maintained. Their bedrooms are comfortable and they have their own possessions around them, however they do not have anywhere to securely store valuables. EVIDENCE: The home employs maintenance staff and has an ongoing programme of maintenance in place. An environmental health department inspection was conducted recently, and the recommendations made have been carried out. The home is pleasantly decorated, comfortably furnished and well maintained throughout. The home employs a cleaner and this was evident by the high standard of cleanliness in the home. Service users bedrooms are comfortably furnished and decorated according to the individual’s taste. All except one have en-suite facilities. All of the bedrooms are personalised with the service users belongings and reflect their individual preferences and interests. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 16 A requirement was made at the last inspection for service users to have a lockable facility in their rooms. Owing to long term sickness of the maintenance worker, this has not been carried out. The requirement has been carried forward. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 and 30 The homes recruitment policy and procedures protect service users, however there is not sufficient evidence to show that members of staff are trained to carry out their jobs. EVIDENCE: The home has a recruitment policy and procedure that is followed when employing new members of staff. A number of personnel files were examined and found to contain all the information and documentation required by the Care Homes Regulations (as amended) 2001. A requirement was made at the last inspection that the home to provide staff members with training soon after commencing employment. A training programme has now been put into place, however it is not due to commence until 16th June 2005 and no records of recent training were available to examine. The requirement has been carried forward and a further requirement has been made that the registered person maintains accurate and accountable records of training for all members of staff. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38 Service users financial interests are safeguarded and their health, welfare and safety are promoted by the home. EVIDENCE: The home is not involved in service users finances. Any services provided are invoiced directly to the service user or their representative. A small amount of money is held for each service user for personal expenditure and robust procedures are in place for the accounting of this. The home has a health and safety policy in place and audits are carried out monthly. Any shortfalls identified are recorded along with actions taken to resolve them. The ‘fire log book’ was examined and found to have records of fire alarm tests, drills and servicing of fire safety equipment. All staff have received fire safety training and this was recorded. Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x 2 x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 3 x x x x 3 x x 3 Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 24 Regulation 16 (1) Requirement The registered person must ensure that all service users have a lockable facility in their bedrooms for the storage of private effects and valuables. The registered person must ensure that the training needs of new members of staff are adressed soon after employment. The registered person must ensure that accurate and accountable records of training are maintained for all staff members. Timescale for action 06/08/05 2. 30 18 (1) (c) (i) 06/07/05 3. 30 17 (2) Schedule 4 (6) (g) 06/07/05 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. Refer to Standard 7 14 Good Practice Recommendations It is recommemded as good practice that service users care plans are signed by themselves, or a representative, and a record made on the plan if this is not possible. It is recommended that when service users meetings are held, the outcome of issues raised at the previous meeting are discussed and recorded. H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 21 Oak House Oak House H58 H09 s49203 Oak House v223764 060605 Stage 4 ann_UPDATED.doc Version 1.30 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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