Inspection on 28/10/05 for Oak Tree Lodge

This inspection was carried out on 28th October 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 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 Lodge 09/12/08

Oak Tree Lodge 14/12/07

Oak Tree Lodge 11/10/06

Oak Tree Lodge 27/06/05

Oak Tree Lodge 24/11/04

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 Lodge 12 Jesmond Road Clevedon North Somerset BS21 7RZ Lead Inspector Margaret Dean Announced 27 & 28 October 2005 th th 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 Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Oak Tree Lodge Address 12 Jesmond Road, Clevedon, North Somerset, BS21 7RZ 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) 01275 873171 01275 870920 oaktreeltd@btconnect.com Oaktree (Clevedon) Ltd Ms June Keating PC Care Home only 34 Category(ies) of Old age (34) registration, with number of places Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27th June 2005 Brief Description of the Service: Oak Tree Lodge is set on a hill in a residential area close to local amenities and the town centre. It provides residential care for up to 34 elderly residents in a homely environment. Plenty of in-house activities and entertainment are provided as well as regular local outings for which there is no charge. The home emphasizes the importance of staff and families getting to know each other well so that residents can be offered the best possible service. The home is on four floors and there is a passenger lift to all levels. Thirty of the bedrooms are single, eleven of them have an en suite bathroom and seven have an en suite toilet. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was undertaken over two full days. The home was fully occupied on this occasion, with two of the double rooms having single occupancy. Twelve of the residents and one visitor were consulted and all were very happy in the home and appreciated the care provided. This included some residents, who had recently moved in. In addition, the Commission received 22 responses from relatives or residents and all made positive comments about the home. These included ‘staff work hard to make it feel like home’ and ‘residents are offered a varied and interesting weekly routine’. As well as seeking residents’ views, this inspection focused upon management processes and care practices in the home. A range of records were reviewed to assist this process. The registered provider, Ms June Keating, has been appointed as the manager since the last inspection. She has daily contact with the residents and is concentrating on bringing the documentation up to date. What the service does well: What has improved since the last inspection? The new system of care documentation continues to be used in the home and the manager recognised that staff would use it more effectively as they became more familiar with the format. The programme of staff training has continued. All the care staff were either undertaking or had completed the NVQ programme at level 2 and some had progressed to level 3. The home’s Statement of Purpose and Service User’s guide continues to be reviewed to ensure that it is up to date. The manager was also in the process of updating all policies and procedures. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 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 Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 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 Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 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, 2, 3, 4 and 5 Prospective and existing residents are provided with a comprehensive guide to services provided in the home and this assists them in making choices in their daily lives. Any prospective service user is assessed prior to admission to ensure that their needs can be met and that they will enjoy living in the home. EVIDENCE: The home’s Statement of Purpose and Service User’s guide were available in the reception area and a copy is given to anyone making an inquiry and each new resident. An ‘A to Z of the Home’ provided valuable information about services provided and routines in the home. Prospective service users are assessed prior to admission or relevant information obtained if they are coming from another part of the country. This gives staff the opportunity to ensure that their needs can be met and they will be able to integrate with the existing residents. The new care documentation, recently introduced, provides a clear format for recording this information and should be used to its full advantage. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 Page 9 New service users are invited to visit the home for a day to meet the other residents. They are then admitted for an initial trail period of one-month before making a decision regarding permanent occupancy. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 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, 8, 9 and 10 Residents spoke positively about the caring attitude of the staff and how they were always treated with dignity and respect. However they should be involved in planning and reviewing their care needs whenever possible. Risk assessments also need to be undertaken as appropriate. EVIDENCE: Comments made by the residents confirmed that they were treated with respect and dignity at all times. They were very confident in the way in which staff cared for them. A comprehensive system for assessing and recording each resident’s care needs has been introduced. Assessments had been undertaken and initial care plans put in place but these could be developed further. The care plan should direct staff in how care needs are to be met and document any changes identified at each monthly review. Residents should be involved in this process as much as possible. Very few risk assessments had been recorded although some residents were at risk, particularly of falling. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 Page 11 Other pages in the system could be used to greater advantage but it was noted that any healthcare professional’s visit was recorded on each occasion. Information given and action taken was clearly recorded. Pharmacy provision in the home has recently been changed and senior staff were still adjusting to a new process. The new pharmacist was already providing valuable support to the home. Medications administered were recorded and stocks held were within acceptable limits. Although Controlled Drugs were kept in a locked cupboard, appropriate storage, which meets the legal requirements must be provided and secured to a solid wall. Some residents were able and encouraged to manage some of their own medication. Risk assessments should be carried out with these residents to ensure that they were aware of their responsibility in this aspect of care. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 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, 14 and 15 The weekly newsletter provides residents with details of all the social activities taking place each week and they are able to decide how they wish to spend their time. They were all very complimentary of the meals served and, although aware choices were available, felt that staff knew what they liked and disliked. EVIDENCE: A varied programme of social activities continues to be offered and residents said how much they enjoyed this. They are kept up to date with each week’s activities in the regular newsletter. This comments on past activities, future plans and any other interesting information about day-by-day events in the home thereby assisting residents in choosing how they spent their time. A highlight of this week’s events was the publication of a poetry book containing verses composed by residents. This was greeted with much enthusiasm. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 Page 13 Residents said that meals served in the home were always very good. They were aware that they could have a choice but usually the staff knew what they liked and disliked. They particularly enjoyed the roast dinners served twice a week. A light supper was served in the early evening and they said that this was sufficient for their needs. They were able to have a hot meal or a selection of sandwiches. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 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) 16, 17 and 18 Residents had no complaints but were confident that any issues raised would be fully investigated. Staff had received training in the protection of vulnerable adults but this needs to be supported by an in-house policy. EVIDENCE: A copy of the home’s complaints procedure was available in the Service User’s guide and on display. Residents said ‘there was nothing to complain about’ and were able to speak to the manager or senior staff if they wished. Two complaints that had been made in the past six months had been fully investigated. The complainants were informed of the outcome and were satisfied. Several of the residents had followed recent political elections with interest and had attended the local polling station to cast their votes. Staff had received training that week in the protection of vulnerable adults. This now needs to be supported by a policy in the home and a copy of the Local Authority guidelines ‘No Secrets in North Somerset’. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 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) 26 Residents live in a clean and well-maintained environment. EVIDENCE: These standards were not reviewed on this occasion as this was undertaken at the last inspection. However residents commented that the home is ‘always clean’ and is a ‘happy environment’ in which to live. Three domestic staff are on duty each day to ensure these standards are maintained. The programme of redecoration and refurbishment, where necessary, continues and one room seen had been prepared for a new resident. Service records for the facilities were reviewed and these were up to date. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 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 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) 27, 28,29 and 30 Residents are cared for by a well-trained and competent group of staff. EVIDENCE: The number of staff on duty varied throughout the day with an emphasis on sufficient staff at busy times. It was also evident that extra staff had been provided if a resident required extra care. This was supported by residents’ comments that staff were always available to assist them if they needed help. Each staff member now has a comprehensive employment file and it was clear that robust recruitment procedures are followed. Ms Keating did comment that it was still taking a long time for Criminal Record Bureau checks to be returned. She emphasised that staff continue to work under supervision until a satisfactory response is received. All staff are offered a regular programme of training, which they said made their jobs more interesting. All the care staff had achieved or were studying the NVQ in care at level 2. Several were working towards or had achieved level 3. A training matrix recorded training sessions undertaken or planned for the near future. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 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 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) 31 - 33; 35 - 38 Urgent attention is required to ensure that staff follow safe fire procedures and systems are tested as recommended so that residents are not at risk from a fire in the home. Records must also be maintained of any accident or incident, which affects the wellbeing of a resident. EVIDENCE: Ms Keating, the registered provider, has recently been appointed as the registered manager and is studying for the Registered Manager’s award. She has delegated responsibility for day-to-day management of care issues to her deputy and senior care staff but is always available to offer advice and support. Residents said that she is in the home every day and she is always willing to listen to any concerns that they may have. She has initiated a programme of supervision for the staff and is training senior staff to assist in this process. Financial records for individual residents were up to date and in order. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 Page 18 A range of records were reviewed on this occasion and, as previously stated, some are still in the process of development. This must include records of any accident or incident occurring in the home, which affects the wellbeing of a resident. The fire alarms were set off during the course of the inspection and the Fire Brigade attended the home. Fortunately a minor event caused the alarm and the residents were not at risk. However it was alarming to see that staff failed to follow the correct procedures and wedged open a fire door in the ground floor corridor immediately following this incident. An immediate requirement was made to stop this practice and the manager advised that she would take urgent action to address the issue. It was also noted that there was no record that the fire alarms were tested or fire-fighting equipment checked as recommended by the Fire Brigade. This also requires urgent action. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 3 15 3 COMPLAINTS AND PROTECTION x x x x x x 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 Standard No 16 17 18 Score 3 3 2 3 3 3 x 3 3 2 1 Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 Page 20 No 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. 2. Standard 7 9 Regulation 15(2) 13(2) Requirement Residents must be involved in reviewing their care needs whenever possible. Controlled drugs must be stored in a cupboard, which meets legal requirements and is secured to a solid wall. A policy for the protection of vulnerable adults from abuse must be available to staff. Any accident or incident must be recorded in detail. Fire doors must not be wedged open. Fire alarms and fire fighting equipment must be tested as recommended and recorded. Timescale for action 31/12/05 31/12/05 3. 4. 5. 6. 18 37 38 38 13(6) 17(2) 23(4) 17(2) 31/01/06 28/10/05 28/10/05 28/10/05 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. Refer to Standard 7 Good Practice Recommendations Care plans should direct staff in how residents care needs should be met. Oak Tree Lodge D53 - D02 S61676 Oak Tree Lodge V244928 27&281005 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Riverside Chambers Castle Street Taunton TA1 4AL 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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