Inspection on 12/09/05 for Oak Tree Mews

This inspection was carried out on 12th September 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 Mews 12/10/06

Oak Tree Mews 09/02/06

Oak Tree Mews 10/01/05

Oak Tree Mews 13/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Oak Tree Mews Hospital Road Moreton-in-Marsh Gloucestershire GL56 0BL Lead Inspector Sharon Hayward-Wright Announced 12 September 2005 10:45 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 Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Oak Tree Mews Address Hospital Road Moreton-in-the-Marsh Glos GL56 0BL 01608 650797 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) Southern Cross Healthcare Services Ltd To be appointed Care Home 20 Category(ies) of OP Old Age (20) registration, with number of places Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 10/1/05 Brief Description of the Service: Oak Tree Mews is a modern Cotswold stone family home, which has been extended and converted into a care home. It is located in a quiet no through road in close proximity to the High Street of the market town of Moreton-in-Marsh. The local hospital is within walking distance. The accommodation is on two floors, the ground floor having a number of bedrooms and the communal areas, which consist of a lounge/dining room and conservatory. On the first floor are the remaining bedrooms and a shaft lift providing access to this floor. Fifteen bedrooms have en-suite facilities. The remaining two have toilets adjacent. Eighteen bedrooms are for single occupancy, while the remaining room, although registered as a double, is used by one service user. There is easy access from the home to the large, welltended gardens, which have a number of parking spaces in front of the building. To the rear of the property there are open views to the countryside. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 6 hours on one day in September 2005 by two inspectors. Six service users were spoken with to gain their views on the home; the care of three service users was examined in detail and four staff members were also spoken to, as well as the Operations Manager for the area from Southern Cross and temporary Manager from another home. Staff were observed going about their duties and interacting with each other and service users. The requirements and recommendation made at the last inspection were followed up and records relating to the homes’ Statement of Purpose, Service Users Guide, service users care, duty rotas, staff training, staff personnel files, service users monies and servicing of equipment were inspected and a tour of the home took place with a number of service users rooms inspected. The home has not had a Registered Manager in post for over a year and a recently appoint Manager left due to personal issues. This has resulted in the home not having permanent management cover and a number of requirements issued at this inspection relate to this. What the service does well: What has improved since the last inspection? The home has now started to review risk assessments for service users on a more frequent basis. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 6 Once finalised the homes Statement of Purpose and Service Users Guide will provide service users and prospective service users with comprehensive details of the services provided, enabling an informed decision for those planning admission to a home. Copies of the unannounced monitoring visits by Southern Cross, are now being sent to the Commission for Social Care Inspection on a monthly basis. 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 Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.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 Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.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, 3, & 5 Once finalised the home’s Statement of Purpose and Service Users Guide will provide service users and prospective service users with comprehensive details of the services provided, enabling an informed decision for those planning admission to a home. No evidence was found to suggest that the home has assessed prospective service users needs and assured them the home can meet their needs. Prospective service users and their family/friends are able to visit the home prior to moving in to make an informed choice. EVIDENCE: The homes draft Statement of Purpose and Service Users Guide was examined and a number of minor amendments were suggested to the Company. This will be followed up once the guides are finalised. The care plans of one recently admitted service user were examined. There was no evidence of a pre admission assessment, only an assessment part completed on the day of admission. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 9 The home must be able to confirm that they can meet the needs of a proposed service user and an assessment of their needs must be undertaken by someone who is suitably qualified or trained and a copy kept in the home. This service user confirmed that they had seen the home prior to admission. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.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 & 10 Care plans examined did not reflect service users current needs therefore they do not provide staff with the information they need to satisfactorily meet the needs of the service users. Service users are able to access health professionals as needed. Personal support is offered in such a way to promote and protect service users privacy and dignity. EVIDENCE: Three service users had their care examined in detail. One service user recently admitted to the home had an assessment of needs started on the day of their admission but it was not completed. A social assessment was also not completed even though this service user has been at the home since the end of May 2005. Care plans were in place and evidence of reviews were seen, however one care plan was not up to date with the individual needs of this service user in relation to showering alone. This must be added to their care plan; however a risk assessment was in place for this service user to shower alone. Risk assessments are completed for moving and handling and nutrition but the risk assessments for continence were not completed. A risk Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 11 assessment completed for stumbling was not dated or signed by the staff member completing it. Detailed daily records were seen. The second service user requires their care plans updating and reviewing in relation to pain relief and an injury to their left hip that happened a year ago. No issues were identified for the third service user. Staff spoken with had a good understanding of the care needs of the service users mentioned above. The home must ensure that the care plans reflect the current needs of the service users. One service user’s care plans were examined and it stated that they require EMI care and from reading the care plans it became obvious that this service user leaves the home at times without staff knowledge and parts of their care requires specialist input. This service user must be reassessed and if the home can no longer meet their care needs, they must be moved to a home that is able to care for their needs. Evidence was seen of visits by health professional to the home. Medication was not examined in detail but at least one member of staff has not been trained to give out medication. All staff must receive training in the tasks they are to perform. Service users confirmed that the staff maintains their privacy and dignity. Staff were witnessed knocking on doors prior to entering service users rooms and addressing them with their preferred form of address. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.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) 13, 14 &15 Service users are able to maintain contact with family and friends and where able participate in the local community. Service users are able to exercise choice and control over their daily lives where able. EVIDENCE: Service users confirmed that visiting is flexible. A number of service users are able to go out into the local village and some relatives take service users out. Service users personal possessions were seen in their rooms. Service users said they are able to make choices about their daily lives where able. Information about advocacy was seen on one of the notice boards by the main entrance. The kitchen was not inspected at this inspection. However lunchtime was observed and seen to be a very social event. Staff offered assistance discreetly when needed. Choices are offered. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 13 All service users compliment the food provided however several service users felt that more fresh vegetable are needed and one service user asked for bigger portions. This was relayed to the staff during the inspection. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.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 From the evidence seen service users and their relatives/friends can be confident that their complaints will be listened to and acted upon. EVIDENCE: A copy of the homes complaint procedure is positioned on the wall in the main entrance and contains the required information as directed in the Care Homes Regulations. The Commission for Social Care Inspection has received one complaint and this was passed to Southern Cross to investigate. However, due to unforeseen circumstances the complaint has been closed and not investigated fully. The Commission for Social Care Inspection are happy with the outcome provided by Southern Cross. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.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) 19, 22 & 26 The standard of the environment within this home is good providing service users with an attractive and homely place to live EVIDENCE: The home is situated in a small town with a number of local amenities close by and the home has views over the local countryside. On the whole the home is maintained to high standards, however several maintenance issues were found during the inspection and in places the decoration looked worn and the home should consider a redecoration programme for these areas. The maintenance issues are: 1) Cracked window panes, one downstairs and one on the landing 2) The door to the medication cupboard has a hole in it and needs to be repaired or replaced. 3) The hot water tap in the upstairs bathroom was dripping and needs repairing. 4) In room F9 there was a hole in the wall. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 16 Where the décor of the home is looking tired it is recommended that service users have an input in to the colours used in their rooms. The outside gardens appeared to be well maintained and a number of service users said they like to sit out in the warm weather. It was found that the upstairs shower room is still being used as storage for the domestic trolley and other items. Alternative storage must be found as this can prevent service users from using the room. The standard of the cleanliness in the home is good with no odours found. Service users confirmed their satisfaction with the cleanliness of the home. Staff were seen wearing protective clothing when required. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 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) 27, 29 &30 The staff demonstrated a good understanding of service users support needs and this was evident from the service users saying they have developed positive relationships with the staff that help to improve their whole quality of life. The standard of vetting and recruitment practices has declined since previous inspection with the appropriate checks not being carried out and potentially leaving service users at risk. There was no evidence to suggest that the staff have received all the appropriate training needed to meet their job roles. EVIDENCE: The off duty rotas were checked as evidence of staffing levels. On an early shift the home has three care staff and one is a senior carer. On an afternoon shift the home has two care staff again one is a senior carer and two waking night staff. The home also employs cooks, domestics and a maintenance person. Service users all praised the staff saying nothing was too much trouble for them and they had developed good relationships with them. Staff spoken to had a good understanding of the needs of the service users. The staff have recently experienced a period of instability but they feel they are through this now. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 18 Personal files of staff appointed since the last inspection, were examined; one file did not have any written references, one had started at the home without evidence that a POVA check had been completed. The Operations Manager said this was not the case but the evidence in the home suggests this staff member started without a POVA check. The application forms used only requested the last five years of career history and the reference forms used did not ask the reasons why the staff member had left their last employment especially if it was a care position as required under the Care Homes Regulations. The Operations Manager said the company has new application and reference forms and was going to ensure the home obtained copies. The training files of a number of staff were checked. No evidence could be found for up to date training in moving and handling, first aid and infection control. Staff spoken with confirmed they had received training in fire and food and hygiene. An induction book of a new staff member was seen and part filled in, as they had not been at the home long. A supervisor had been appointed to the new staff member. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 35, 36 & 38 The management of the home is poor, which has resulted in inconsistent practices, which could potentially place service users at risk. Systems are in place to safeguard service users monies. There is no evidence to suggest that the staff are appropriately supervised. EVIDENCE: The home has not had a Registered Manager in place now for over a year. A new Manager started but has left due to personal reasons. Southern Cross must now appoint a new Manager and send a completed application to the Commission for Social Care Inspection for this person to be considered for registration. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 20 The home has a facility for storing service users monies. This was checked and found to be correct with service users monies held separately and records and receipts kept. There was no evidence to suggest that staff supervision has been taking place. Staff spoken with confirmed they had not received any. Evidence was seen of servicing of equipment, electrical equipment, water temperatures and fire equipment. The Company has devised a health and safety policy. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 x 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 x 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x x 2 x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x x x 3 2 x 3 Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 22 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. Standard 3 Regulation 14 Requirement The Registered Person shall not provide accomodation to a service user at the home unless, so far as is practicable, the needs of the service user have been assessed by a suitably qualified or trained person. The Registered Person must ensure that service users care plans and risk assessments reflect their current needs. The Registered Person must ensure that risk assessments are completed to ensure service users needs are being met. The service user identifed at the inspection must have their care needs reviewed and a copy of this assessment sent to the Commission for Social Care Inspection. The Registered Person must ensure that staff receive the training for the tasks they are to perform in relation to medication. The Registered Person must ensure the maintenance issues identified in the environment section are addressed. The Registered Person must find Timescale for action immediate and ongoing 2. 7 15 immediate and ongoing immediate and ongoing 30/10/05 3. 7 15 4. 7 14 & 15 5. 9 18(1ci) 30/10/05 6. 19 23(2b) 1/12/05 7. 22 23(2L) 1/12/05 Page 23 Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 8. 29 7, 9, 19 & Schedule 2 9. 30 18(1ci) 10. 31 8&9 alternative storage space for equipment rather than using the service users upstairs shower room. Since the introduction of the POVA scheme, and the amendments to the Care Home Regulations on the 26/7/04 for pre-employment checks on staff, the Home must obtain the following for all staff recruited since this date: 1) A POVA check. 2) Two written references, including, where applicable a reference relating to the person’s last period of employment, which involved work with vulnerable adults, of not less than 3 months duration.· 3) Where a person has previously worked in a position which involved contact with children or vulnerable adults, written verification of the reason why the person ceased to work in their last position unless it is not reasonably practicable to obtain such verification.· 4) Full employment history with satisfactory written explanation of reasons for gaps in employment. The Registered Person must provide evidence to the Commission for Social Care Inspection that the training mention below has been provided for staff or provide the training. Training is required in the following: Moving and handling, infection control and first aid. The Regsistered Person must appoint a suitably qualified and experience person to manage the home and apply to the Commission for Social Care immediate and ongoing 30/12/05 30/12/05 Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 24 11. 36 18(2) Inspection to be considered for registration. The Registered person must ensure that staff are appropriately supervised and maintain records to support this. immediate and ongoing RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 7 9 15 19 Good Practice Recommendations The home should ensure that all staff sign and date any assessments that are completed by them. Staff should not adminster medication unless they have been trained to do so. The home should address service users views in relation to meals. The home should consider redecorating the areas of the home that are worn looking and ask for service users input. Oak Tree Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 25 Commission for Social Care Inspection Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB 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 Mews D51 D03 S16517 Oak Tree Mews V243161 120905 Stage4.doc Version 1.40 Page 26 - 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. 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