Inspection on 30/11/05 for Oak Tree House

This inspection was carried out on 30th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Tree House 01/05/07

Oak Tree House 31/05/06

Oak Tree House 18/05/05

Oak Tree House 19/10/04

Oak Tree House 17/06/04

Similar services:

Ravensworth Lodge

Snydale Care Home

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Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Oak Tree House Oak Tree Estate Station Road Preston East Yorkshire HU12 8UX Lead Inspector Lynne Busby Unannounced Inspection 30th November 2005 09:30 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 House DS0000047696.V262037.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 Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Oak Tree House Address Oak Tree Estate Station Road Preston East Yorkshire HU12 8UX 01482 899169 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) PWC Care Limited Mrs Pamela Joy Cawkwell Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (23) of places Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2005 Brief Description of the Service: Oak Tree House is a private residential home. It is situated in the village of Preston within easy access of local facilities and being close to the city of Hull. It is located a short distance from the main road where public transport may be accessed. The home is registered for 23 people over the age of 65 years of either sex. There are bedrooms on the ground and first floor with a stair lift for those service users who are less mobile. There are four shared rooms and fourteen single rooms, seven have ensuite facilities. The home has two lounges and a separate dining room all located on the ground floor. To the rear of the premises is a small car parking area and a garden area that is accessible to service users. Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place over 7 hours and was under taken by one inspector. The inspection process included a review of documentation and a tour of the building. The inspector spoke to staff on duty, the manager, 5 service users and two family members who were visiting the home. What the service does well: What has improved since the last inspection? What they could do better: The electrical installations work identified requiring further work must be carried out. Copies of certificates of work carried out such as the stair lift and that services and facilities comply with the water regulations need to be forwarded to CSCI. There has been some redecoration and programme of replacing furnishings; this should continue to provide service users with a safe, comfortable and wellmaintained home. The recruitment and selection of staff must improve to ensure the safety of the service users. Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 6 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 Tree House DS0000047696.V262037.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 Tree House DS0000047696.V262037.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): 1 and 6 Prospective service users and their representatives are provided with information so they can make an informed decision before being accommodated. The home does not offer intermediate care. EVIDENCE: There is a statement of purpose and service user guide available for service users and their representatives. This has been reviewed and includes all information to allow prospective service users to make a choice before being accommodated in the home. The home does not offer intermediate care. Oak Tree House DS0000047696.V262037.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): 7 The service users health, personal and social needs are met. EVIDENCE: Three service users files were examined and all had a plan of care. However, two did not have community care assessment available. The manager informed me that these had not been forwarded from the care management team. Both service users had recently been admitted to the home and the manager advised she had difficulty getting copies. For service users referred through the care management route the plan of care should be generated from the community care assessment. This provides the basis for the care to be delivered this information and is required at the onset of the service user being accommodated. It is recommended that the manager request this information. Keyworkers review the care plans on a monthly basis and any changes are recorded. Service users are involved in the drawing up of the plan. However, the plan needs to be agreed and signed by the service user whenever capable and /or their representative. Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 10 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): 12, and 15 Service users are able to take full advantage of activities and interests and participate in community and family life. The meals in the home offer choice and variety to the service users. EVIDENCE: The service users are offered some activities within the home. On the day of the inspection a staff member sat with two service users who were doing a jigsaw. Once a month an entertainer visits the home, service users spoken to said they enjoyed this. Two service users go twice a week to a local day centre. Routines of daily living are flexible one service user said “I can get up and go to bed when I want”. Service user religious observance is recorded on service users files and the home will ensure this is met. There is information available on activities; this should be circulated in a format suited to the service users capabilities. Service users are offered three full meals a day. The lunchtime was observed and generally service users were happy with the meals. One service user said, “the meals are good”. Staff assisted those service users where necessary in a sensitive manner. There are hot and cold drinks available at regular intervals. Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 11 There is a four weekly menu available in the dining room. There is a choice at teatime, at lunchtime there is one main meal but service users can ask for an alternative. Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 12 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): 16 and 18 Service users are protected from abuse. Service users can complain and will be listened to. EVIDENCE: The home has a complaints procedure available for service users and their representatives. The home has had two recent complaints; one was made to the home directly the second was made to CSCI. This was referred back to the manager to investigate. One complaint made to the home was regarding the locking of the front door. There was evidence of investigation and outcome it is intended a new front door will be in place with a different locking system, which will offer security but not restrict access. The second complainant was regarding a service user wandering into other service users rooms. This was resolved to the complainants satisfaction and demonstrated that the homes complainants procedure is accessible. The home has a Hull and East Riding Protection of Vulnerable Adults procedure. The manager has developed in house procedures on protection of vulnerable adults and whistle blowing. Staff have not attended any training on protection of vulnerable adults and due to the recent incident the manager is providing training for all staff. There are policies and procedures on service users’ money and financial affairs. This requires further development to include safe storage of valuables, consultation on finances in private and advice on personal insurance in line with the standard. Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 13 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, 24,25 and 26 The service users live in a ‘homely’ environment. Whilst improvements have been made there are still some outstanding concerns that impact on service users comfort. EVIDENCE: The home is located in a village within easy access to local amenities. The home is set in its own grounds, which are well kept. The manager advised further work is being done to the gardens to make them accessible to service users. The home was described by a visitor as ‘homely’. There is a programme of routine maintenance available. There are no outstanding requirements from the fire officer or the environmental health. Service users have access to all parts of the building via a stair lift. The home provides accommodation in single and shared rooms all are furnished and service users can personal their rooms. In shared rooms screening is provided to ensure privacy. Each service users has a lockable storage space. Recently some service users have had locks fitted to their doors Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 14 these are keypads. These need to be risk assessed to ensure they are suitable to service users capabilities and accessible to staff in emergencies. Advise from the fire department is being sought regarding the use of these locks. Oneservice users room had Yale lock on that had been removed, this still had a large part still attached to the door that was sharp and presented a risk. The radiators have all been guarded with the exception of one in the dining room, which is being removed. The washbasins and baths have all been fitted with fail-safe devices to provide water at 43ºC. The laundry facilities are in the process of being redecorated. A new floor has been laid and is impermeable and easy to clean. There are hand-washing facilities in the laundry room. The evidence that services and facilities comply with the Water Supply (Water Fittings) Regulations 1999 need to forwarded to CSCI. The home is clean but in two rooms there is a strong malodour. The manager advised that a cleaning regime is in place and plans are to redecorate and carpet the rooms. Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 15 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): 28,29,30 Service users are not fully protected by the homes recruitment practices. Service users are cared for by trained staff. EVIDENCE: The inspector checked three staff files and found that all had completed CRB checks. One staff had been employed prior to the POVA first check being received at the home. One staff file had no references, however, this staff member had been in post for a number of years. The most recent staff members did not have a health declaration on file. The manager said that these had been completed. One staff member’s file did not include an application form so gaps in employment could not be explored. All staff receive a statement of terms and conditions. There are six staff who have completed NVQ level 2 and a further four staff are working towards this. The staff have attended a number of training events it is recommended that they complete training in working with people with dementia. Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 16 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): 33,35,38 Service users best interests are provided for and their financial interests are safeguarded. The environment is safe and the welfare of staff and service users is promoted. EVIDENCE: The home has developed an in house quality assurance system and has been awarded Parts 1 and 2 of the East Riding Social Services Department Quality Development Scheme. The development plan for the home and published results of the surveys is required to be sent to CSCI. Maintenance records were in place for portable appliance testing, electrical installations and gas. However, the electrical installations identified a number of outstanding areas that required work. An immediate requirement was issued for this to be completed. There are risk assessments for the safe working practices and fire. The manager was not available in the afternoon and the Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 17 following evidence was not accessible maintenance certificates for the stair lift and medi-bath and evidence that the services and facilities comply with the Water Regulations 1999. There is a safe available to securely store money and valuables. The manager said she was not an appointee for any service user. The inspector tracked two service users files and monies stored were checked and accurate. Records are kept on computer and receipts are kept. Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X 3 3 STAFFING Standard No Score 27 X 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 3 X X 1 Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 19 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 OP7 Regulation 15 Schedule 3 Requirement Timescale for action 31/03/06 2 OP18 16,20 3. OP29 18 4. OP33 24(a)(b) (2)(3) The registered provider must ensure that the plan is drawn up with the involvement of the service user; agreed and signed by the service user or their representative. (Previous requirement-timescale 30/06/05- not met). The registered provider must 31/03/06 ensure the homes policies and procedures and practices regarding service users money and financial affairs covers all areas identified in the standard. (Previous requirement -timescale 31/07/05 - not met). The registered provider must 31/01/06 ensure the recruitment and employment policies and practice comply with the standard. All records in Schedule 2 of the Care Homes Regulations 2001 must be in place for staff. (Previous requirement -timescale 30/06/05- not met). The registered provider must 31/03/06 ensure that an annual development plan for the home, based on systematic cycle of DS0000047696.V262037.R01.S.doc Version 5.0 Oak Tree House Page 20 5 OP38 13(4) 6 OP38 13 planning. The results of surveys must be published and made available to service users and representatives and the Commission for Social Care Inspection. The electric installations certificate must be forwarded to CSCI. (Immediate requirement issued). The registered provider must forward to CSCI copies of the maintenance certificates for the stair lift and medi-bath and evidence that the services and facilities comply with the Water Supply (Water Fittings) Regulations 1999. 21/12/05 21/12/05 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. 3. Refer to Standard OP12 OP28 OP30 Good Practice Recommendations An activities programme should be circulated to service users in format suitable to their capabilities. 50 of the staff should be trained to NVQ level 2 or equivalent by the end of 2005. Staff should have training in working with dementia. Oak Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Tree House DS0000047696.V262037.R01.S.doc Version 5.0 Page 22 - 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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