Inspection on 09/02/06 for Oak Tree Mews

This inspection was carried out on 9th February 2006.

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 Tree Mews 12/10/06

Oak Tree Mews 12/09/05

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 Glos GL56 0BL Lead Inspector Sharon Hayward-Wright Unannounced Inspection 9th February 2006 10:20 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 Mews DS0000016517.V281199.R01.S.doc Version 5.1 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 Mews DS0000016517.V281199.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Oak Tree Mews Address Hospital Road Moreton-in-marsh Glos GL56 0BL 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) 01608 650797 01608 652735 Southern Cross Healthcare Services Limited To be Appointed Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Oak Tree Mews DS0000016517.V281199.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2005 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 DS0000016517.V281199.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours on one day in February 2006. Five service users were spoken with to gain their views on the home; and four staff members were also spoken to, as well as the new Manager. 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 service users care, staff training, and staff personnel files were inspected. A part tour of the home also took place with a number of service users rooms inspected. The home has recently appointed a new Manager; service users and staff spoken to all felt the home is now moving forward. They also felt she was approachable and the changes she has made in the short time she has been at the home are all positive. Seven requirements remain outstanding since the last inspection, however the new Manager is working towards addressing these. No further requirements were issued at this inspection. What the service does well: What has improved since the last inspection? Oak Tree Mews DS0000016517.V281199.R01.S.doc Version 5.1 Page 6 Systems are now in place to ensure service users are not admitted to the home without first having their needs assessed. Since the last inspection the standard of vetting and recruitment practices has greatly improved with the appropriate checks now taking place. Training opportunities are being provided for staff to improve their skills but there are inconsistencies with not all staff receiving training. However the Manager is in the process of organising some of the training that is outstanding. Southern Cross has now appointed a Manager to the home; staff and service users all feel she is making good progress in improving the home for those who live and work there. Systems are now in place to ensure the staff are appropriately supervised. The systems for administration of medication are good, however, lack of training leaves service users at risk. The new Manager has started their quality assurance procedures and from this will devise any action plans required. 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 DS0000016517.V281199.R01.S.doc Version 5.1 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 Mews DS0000016517.V281199.R01.S.doc Version 5.1 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): 3 Arrangements are in place now to ensure service users are not admitted to the home without first having their needs assessed. EVIDENCE: A requirement was issued at the last inspection for the home to undertake preadmission assessments on all proposed service users, as the home had admitted a service user without an assessment. The new Manager had undertaken a detailed assessment of a service user admitted for respite care and had identified any problems. Oak Tree Mews DS0000016517.V281199.R01.S.doc Version 5.1 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&9 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. The systems for administration of medication are good, however, lack of training leaves service users at risk. EVIDENCE: Standard 7 was not assessed in full only the requirements issued at the last inspection. Two care plans were examined in detail. The new Manager had recently audited one and similar issues to what is listed were identified. Continence assessments were not completed even though the Continence nurse has assessed one service user. Some risk assessments were not signed or dated. One care plan did not reflect what was being written in the daily records and the risk assessments for moving and handling and pressure sores had not been reviewed as the last entry dated 12/1/06 said ‘in hospital’. Two of the requirements issued at the last inspection have been repeated again. Oak Tree Mews DS0000016517.V281199.R01.S.doc Version 5.1 Page 10 Medication was not examined in detail only the requirement issued at the last inspection. This was to ensure staff receive training in relation to medication. The new Manager said that training is booked Oak Tree Mews DS0000016517.V281199.R01.S.doc Version 5.1 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): 12 Activities are made available for service users to participate in if they so wish, however service users interests are not always being addressed. EVIDENCE: From discussions with service users they felt that activities are now starting to take place again following the appointment of the new Manager. Several service users were out for a walk during the inspection and some had gone out for lunch. The minutes of a service users meeting contained details of activities that have been provided. The new Manager said that while the redecoration programme is taking place activities in the home would be limited. One service user said they miss going out on the mini bus for a trip as the last time this happened was over one year ago. The new Manager has some ideas in hand for activities once the redecoration has taken place. Oak Tree Mews DS0000016517.V281199.R01.S.doc Version 5.1 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): 18 Systems are in place for protecting vulnerable adults from abuse. EVIDENCE: The home has polices and procedures in place in relation to protection of vulnerable adults and abuse. One member of staff said they covered this topic in their NVQ 2 training. The new Manager said training in relation to this subject is booked for March. Oak Tree Mews DS0000016517.V281199.R01.S.doc Version 5.1 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 & 22 The home is in the process of planning redecoration programme and this will greatly improve the environment for the service users. EVIDENCE: The standards in this section were not inspected in detail only the requirements issued at the last inspection. A number of minor maintenance issues were identified then and all but one has been addressed. This is for the hot water tap in the upstairs bathroom to be repaired as it dripping constantly. The new maintenance man is going to address this immediately. Another requirement was issued to find alternative storage for equipment other than the upstairs shower room. The new Manager said she is part way to addressing this but due to the redecoration of the home this has been delayed. The home is going to be redecorated in the next few weeks and new carpets have been fitted in the corridors. This redecoration programme will greatly improve the environment for the service users. Oak Tree Mews DS0000016517.V281199.R01.S.doc Version 5.1 Page 14 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 Since the last inspection the standard of vetting and recruitment practices has greatly improved with the appropriate checks now taking place. Training opportunities have been provided for staff to improve their skills but there are inconsistencies with not all staff receiving training. EVIDENCE: One member of staff has NVQ 2 qualification and two are due to complete very soon. The new Manager is aware of the recommendation of 50 care staff trained in NVQ 2. Standard 29 was not inspected in full only the requirement issued at the last inspection. A personnel file of a new member of staff was examined and found to contain all the required checks and documentation. This has improved since the last inspection. Standard 30 was not inspected in full only the requirement issued at the last inspection. Staff said they have had some moving and handling training since the last inspection but first aid needs to be arranged and infection control is booked. This requirement has been repeated again. Oak Tree Mews DS0000016517.V281199.R01.S.doc Version 5.1 Page 15 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): 31, 32, 33 & 36 The new Manager has a supportive, open approach to running the home, which benefits the service users, staff and relatives. Since the appointment of the new Manager, the home has started to reassess aspects of its performance through a good programme of self-review, which will include seeking the views of service users, relatives and staff. Systems are now in place to ensure staff receive appropriate supervision. EVIDENCE: Since the last inspection the home has appointed a new Manager; she has been at the home for 5-6 weeks. The Manager is going to apply to the Commission for Social Care Inspection to be considered for registration. Oak Tree Mews DS0000016517.V281199.R01.S.doc Version 5.1 Page 16 From discussions with service users and staff they feel the new Manager is moving the home forward in the right direction. All said she is friendly and approachable. One service user commented that this Manager comes and talks to them individually. The Manager is about to send out questionnaires to service users and staff. She has already undertaken an audit of the home, medication and has started on care plans. This is part of Southern Cross quality assurance procedures. A requirement was issued at the last inspection for the home to ensure staff are appropriately supervised. The new Manager has started supervision sessions with staff and is looking to devise a schedule. Oak Tree Mews DS0000016517.V281199.R01.S.doc Version 5.1 Page 17 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X 2 X X X X STAFFING Standard No Score 27 X 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X X X X X Oak Tree Mews DS0000016517.V281199.R01.S.doc Version 5.1 Page 18 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 OP7 Regulation 15 Requirement The Registered Person must ensure that service users care plans and risk assessments reflect their current needs. Timescale of the 12/09/05 was not met. The Registered Person must ensure that risk assessments are completed to ensure service users needs are being met. Timescale of the 12/09/05 was not met. The Registered Person must ensure that staff receive the training for the tasks they are to perform in relation to medication. Timescale of the 30/10/05 was not met, however the home has training planned. The Registered Person must ensure the hot water tap in the upstairs bathroom is repaired as it is leaking all the time. Timescale of the 01/12/05 was not met. The Registered Person must find alternative storage space for equipment rather than using the DS0000016517.V281199.R01.S.doc Timescale for action 01/05/06 2. OP7 15 01/05/06 3. OP9 18(1ci) 01/05/06 4. OP19 23(2b) 01/05/06 5. OP22 23(2L) 01/05/06 Oak Tree Mews Version 5.1 Page 19 6. OP30 18(1ci) 7. OP31 8&9 service users upstairs shower room. Timescale of the 01/12/06 was not met. 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: infection control and first aid. Timescale of the 30/12/05 was not met. The Registered Person must appoint a suitably qualified and experience person to manage the home and apply to the Commission for Social Care Inspection to be considered for registration. Timescale of the 30/12/05 was not met. 01/06/06 01/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP7 OP12 Good Practice Recommendations The home should ensure that all staff sign and date any assessments that are completed by them. The home should obtain the views of service users on mini bus outings and look to arrange some if asked for by the service users. Oak Tree Mews DS0000016517.V281199.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Gloucester Office 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 DS0000016517.V281199.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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