Inspection on 25/10/05 for Oak Lodge Rest Home

This inspection was carried out on 25th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Lodge Rest Home 07/01/09

Oak Lodge Rest Home 23/01/07

Oak Lodge Rest Home 12/05/05

Oak Lodge Rest Home 07/01/05

Oak Lodge Rest Home 31/08/04

Oak Lodge Rest Home 17/04/03

Oak Lodge Rest Home 17/04/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Oak Lodge Rest Home 1a Adams Road Shire Oak Brownhills West Midlands WS8 7AL Lead Inspector Lesley Webb Unannounced Inspection 25th October 2005 10:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 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 Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Oak Lodge Rest Home Address 1a Adams Road Shire Oak Brownhills West Midlands WS8 7AL 01543 372078 01543 372078 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) Mr David Alan Wilson Mrs Pamela Mary Wilson Mrs Pamela Mary Wilson Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12 May 2005. Brief Description of the Service: Oak Lodge is a two storey detached property located in a quiet residential area of Brownhills. The building comprises of fourteen single bedrooms, many with en-suite facilities, a lounge, separate dining room, kitchen and laundry. There are parking facilities to the front of the property and a small, enclosed garden, with patio to the rear. The home is approximately one mile from the centre of Brownhills, close to bus routes to other towns, shops and other amenities. Oak Lodge is registered to provide care for up to fourteen older people of both sexes for the reason of old age. Over the past two years a number of improvements to the building have been made, including the installation of a passenger lift, improving facilities offered to service users, with the next phase of building work currently in process to increase bed spaces from fourteen to seventeen. Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at 10.45am and stayed until 4.00pm. During the visit time was spent talking to residents (3 in private), interviewing 3 staff, looking at records and observing care practices before giving feedback about the inspection to the registered manager. 8 residents and 4 relatives comment cards have been received by CSCI. All praise the service offered at the home, for example one stated, ‘I am really happy with Oak Lodge, it is a very friendly and happy home’. This is the second inspection to take place at the home this year and therefore both this report and the one published in May should be read when looking at information regarding the home. By the end of the visit the inspector was satisfied that generally the home offers a very good service. The inspector would like to thank residents and staff for their co-operation and assistance during the visit, where she was made to feel very welcome. What the service does well: All the residents told the inspector how “friendly” staff are and how they make visitors welcome. For example one person said, “my daughter comes every week, we like to sit in the lounge and chat to the staff. They always make her a cup of tea”. Praise was also given by the family of a service user who were visiting on the day of inspection. They stated, “Whenever we visit we are always made to feel very welcome. Staff always keep us informed of what’s happening to mother, they understand how important this is”. Residents bedrooms are furnished and decorated in a way that makes them feel ‘homely’. Furniture is domestic in nature and residents are allowed to bring personal items such as ornaments and pictures to personalise their bedrooms. The inspector found lots of evidence that residents are supported to make choices and take control of their lives. Examples include being able to vote, choosing what time to get up and go to bed, joining in activities, meals and Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 6 where to receive their visitors. All the residents confirmed that staff respect their wishes and listen to their requests. 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. Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 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 Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 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 the following standard(s): 6 – not applicable. EVIDENCE: The home does not offer intermediate care. Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 and 9. Recent improvements to monitoring systems ensure the health needs of residents are met in full. The home has made limited progress with regards to improving its medication policies and procedures, which although not placing residents at risk, results in a system that may not comply with legislation. EVIDENCE: Previous requirements relating to accessing medical services and maintaining health records have now been met by the home. The inspector was shown a new recording system that has been implemented that ensures effective monitoring and auditing of residents health appointments now takes place. Since the last inspection the home has sent its medication policies and procedures to CSCI’s pharmacy inspector for his advice. Several recommendations have been made which the home is yet to implement. Records for the receipt, administration and disposal of medication were viewed and found to be in order. In the main medication was found to be managed correctly apart from a nasal spray that had not been dated when opened and Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 10 another that was being administered past its usage date. All staff that were interviewed demonstrated knowledge of residents rights to self medicate. For example one person stated, “As part of the needs led assessment this is discussed. If people want to self medicate they sign a consent form and a risk assessment is completed that is filed with the relevant care plan”. Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 14. The atmosphere within the home is friendly and welcoming towards visitors, creating an inclusive place for residents to live. Staff’s excellent knowledge of resident’s rights and responsibilities ensures people living at the home can exercise choice and control over their lives. EVIDENCE: All residents that the inspector spoke to confirmed that their visitors are made welcome in the home. For example on person stated, “My son and his wife visit every week. Normally they come and sit in my room because its nice and private” and another said, “staff are friendly towards visitors”. Staff that were interviewed confirmed that the home promotes contact with friends and families with responses that included, “we help one resident to telephone her sister and take her once a week to visit her. We always try to make visitors welcome by offering drinks”. Staff and records also confirmed that residents are able to receive their guests in the privacy of their own bedroom if they so wish and that the only restriction on visiting times are when meals are being served due to the disruption this can cause to others. The inspector also noted Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 12 that the visitor’s policy requests people not to visit the home if they have illnesses such as the flu due to the risk of passing this on to others. Two families of residents were at the home on the day of inspection, both of which also confirmed that they are always made welcome and are kept informed of important issues regarding the care of their relatives. The inspector asked staff how they help residents to take control and exercise choice in their lives. Again everyone demonstrated knowledge in this area with responses that included, “ we involve them in the compilation of their care plans, give choices at mealtimes and ask their opinions via the questionnaires we send out. We speak to people, sit down and talk to them to try to find out if they have any ambitions or needs not being met”. Residents also gave examples relating to choice and control including their rights to vote, choices in what time they rise and retire at night, what they wear and looking after their own finances. When discussing this choice and control with the manager she confirmed that they had attempted to access advocacy services in the past but had not been successful, with many residents relying on relatives to undertake this role. The inspector recommended that the home obtains details of independent advocates as an addition service available to people living at the home. Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 13 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 the following standard(s): Standards assessed at last inspection. EVIDENCE: Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 19 and 24. Generally the standard of the environment within this home is good, providing residents with an attractive and homely place to live. EVIDENCE: Presently building work is being undertaken at the home to increase bed spaces from fourteen to seventeen and to create an additional 3 en-suite facilities. The inspector was informed that a requirement identified in previous inspections to provide a sluicing facility would be addressed as part of the work being carried out. The inspector was invited by two residents to view their bedrooms. Both were found to be comfortable and homely, with many personal items including ornaments and photographs. Both residents expressed their appreciation that the home allows people to bring their own possessions when moving in, for example one stated, “my rooms nice, when I’m lying in bed I can see photographs of my family that I brought with me, it’s lovely”. Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 15 All bedrooms are lockable and everyone that the inspector spoke to confirmed they had been offered a key to this facility but had declined. One resident stated, “I didn’t take them up on the offer, I’m happy to shut my door, the staff always knock before coming in”. Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30. The arrangements for the induction of staff are good, with the staff demonstrating a clear understanding of their roles. EVIDENCE: The inspector was shown documentary evidence that staff receive induction training on their first day of employment that complies with TOPPS guidance. The manager stated that the home is looking to introduce the new ‘Skills For Care’ induction standards as it is felt this will benefit people who work at the home. As part of the homes induction process new staff shadow senior workers before commencing shifts in their own right. The manager explained that the amount of shifts undertaken depends of the experience and training that new staff have, but can be anything from a couple of days to a week. When looking at the training records for staff the inspector instructed that individual training and development assessments must be introduced for each person to further support training systems within the home. All but 2 staff at the home either holds a NVQ level 2 or 3 or is in the process of completing. Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 37 and 38. The home has a good quality assurance system, which ensures the views of residents; staff, relatives and other professionals are listened to and acted upon. Improvements must be made to financial records and policies and procedures to ensure residents are fully protected. Monitoring systems are good in this home, ensuring the health; safety and welfare of residents and staff are promoted. EVIDENCE: A previous requirement to introduce a quality assurance system is now met. The inspector was very impressed with the amount of work that has been undertaken by the home to address this requirement, resulting is a quality assurance system that includes audits of maintenance, residents meetings, CSCI reports, medication and care provision. In addition to this residents, Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 18 relatives, professionals and staff questionnaires have been analysed with action plans put into place, with only an annual audit of the whole quality assurance system now required. The inspector sampled 3 sets of finances held on behalf of residents and found all to be correct. A recommendation is made to develop the recording system that is in place as presently this can lead to confusion when residents run out of money and are subsidised by the home. It was also noted by the inspector that a separate audit of the total amount of monies is not maintained and the maximum amount that is covered by the homes insurance is unknown. The inspector explained that these issues must be addressed to ensure the protection of people using this facility. Residents that the inspector spoke to confirmed that the home helps them look after their money, for example one person said, “I carry a little bit on me, I have a drawer that locks in my bedroom but prefer the manager to look after my money”. The home has policies and procedures that work in conjunction with regulations and national minimum standards. When sampling some of these and looking at documentation supplied prior to the inspection 5 were found to be either missing, not in place or requiring development. The home previously supplied CSCI with a pre-inspection document that detailed maintenance and associated records kept at the home relating to health and safety. After discussing the contents of this with the deputy on duty the inspector was satisfied that the health and welfare of residents and staff is maintained. For example the fire department visited the home in June 2005 with all requirements addressed, staff undertook fire training in September 2005, a legionella assessment was completed September 2005 (awaiting certification) and adaptations such as wheelchairs were inspected in August 2005. Records and discussions with the deputy also confirmed that staff at the home hold certificates for moving and handling, food hygiene and first aid, with only health and safety being required. Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 4 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x x x 3 x 2 STAFFING Standard No Score 27 x 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 2 x 2 2 Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13(2) Requirement The home must implement all recommendations made by the pharmacy inspector. The date must be recorded when nasal sprays are opened for use. No medication must be administered if past its usage date. The home must obtain copies of the reports completed by the supplying pharmacist A sluice must be provided separately from service users toilets – Requirement originally made January 2005. All staff must undertake bereavement training Requirement originally made May 2005. All staff files must contain a recent photograph and two forms of identification (one of which must be a copy of birth certificate – Part met. Requirement originally made DS0000020823.V260033.R01.S.doc Timescale for action 31/12/05 2 OP26 16(1) 31/01/06 3 OP27 18(1) 31/01/06 4 OP29 4, 6 31/12/05 Oak Lodge Rest Home Version 5.0 Page 21 5 6 OP30 OP32 18(1) 10(1) 7 8 OP33 OP35 24 13(5) January 2005. Individual training and development assessments must be completed for all staff Service user and staff meetings must occur on a regular basis with minutes maintained – Part met. Requirement originally made May 2005. An annual audit of the quality assurance system must take place A record must be maintained of the total amount of monies held on behalf of residents. This must be kept separately from resident’s individual records. The home must find out how much money its insurance policy allows it to hold on behalf of residents. The home must introduce or develop written policies and procedures for: Racial harassment; Recruitment and employment; Sexuality and relationships; Smoking and use of alcohol; and Working with volunteers. 31/01/06 31/12/05 31/01/06 30/11/05 9 OP37 17 31/01/06 10 OP38 13(3-6) All staff must undertake health and safety training 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 22 No. 1 2 3 Refer to Standard OP14 OP26 OP35 Good Practice Recommendations That the home obtain details of local advocacy services and makes this information available for residents and their families That a sluicing disinfector be installed That the home develops its recording systems relating to residents finances Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. Extracts may not be used or reproduced without the express permission of CSCI Oak Lodge Rest Home DS0000020823.V260033.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!