Inspection on 01/06/05 for Oakcroft House

This inspection was carried out on 1st June 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

Oakcroft House 31/05/07

Oakcroft House 03/10/05

Oakcroft House 30/07/04

Oakcroft House 15/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Oakcroft House Oakcroft House West Byfleet Surrey KT14 6JG Lead Inspector Catherine Campbell-Ace Announced 01 June 2005 10:00 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. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Oakcroft House Address West Byfleet, Surrey, KT14 6JG 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) 0113 3816100 BUPA Care Home Limited Miss Vivien Rosemary Traquair Grieve CRH Care Home 48 Category(ies) of OP Old Age, 48 registration, with number PD Physical Disability, 5 of places PD(E) Physical Disability - Over 65, 5 Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 48 beds providing nursing care for elderly people from the age of 60 years. 2. 5 of these may be used for Physically Disabled people from the age of 40 either PD or PDE. 3. Additionally one named service user age 38 years of age, as per letter dated 9th March 2004, in the category physical disability may be admitted. Date of last inspection 30 July 2004 Brief Description of the Service: Oakcroft House is a long established Nursing Home situated in a quiet residential road in West Byfleet. The home is owned and operated by BUPA Care Homes Ltd. The original property has been altered to provide spacious accommodation for up to 42 persons who require nursing care. Up to six beds at the home are registered to provide nursing care for younger adults. The remaining beds are registered to provide nursing care for the elderly. The home has a well managed large rear garden, of which a part of it has been made into a sensory garden for the service users. There is car parking space at the front of the property. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection lasted 5 hours. The inspection was positive and well received. The service users and staff present were very welcoming and the inspector wishes to extend gratitude to the Manager, service users and staff for their hospitality throughout the inspection process. Care plans, daily records, risk assessments and activities of daily living were written clearly, with signatures of service users and family members evident. One comment card sent to the inspector from a service user stated: ‘Superlative nursing home with top levels of medical and civil authorities, with top levels of care and attention and superb amenities.’ A relative had commented: ‘the quality of care is excellent and the standard of cleanliness is also high. Meals are varied, tasty and most enjoyable. The staff are an impressive team, always helpful and cheerful.’ Service users live in a comfortable, well - maintained home with a sensory garden to the rear of the property. What the service does well: The home has a friendly, relaxed and supportive atmosphere, which helps the service user feel that the home is their own. The nursing care was evidenced to be of a high standard, with service users looking well cared for. Service users gave many positive comments during the inspection, for example, one service user said:’ I’m really happy. I have a lovely room with a balcony, with a view of the garden. I go out to Wisley Gardens. The food is remarkable and the staff delightful’. Staff said when asked what was good about the home: ‘The care is good and the residents are the priority.’ The home offers varying activities for the service users, and employs an activities co-ordinator. While the inspection was taking place, the service users were given a demonstration of decorating a cake with icing sugar. Others were painting a picture, one service user was knitting squares which would eventually be made into a blanket for a dog at the dog’s home. Other service users were socialising with others and some were receiving visitors. The home has two cats, one of which was evident throughout the inspection. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 6 The home has a core of staff employed for many years, and when the inspector spoke to them, said that they enjoyed the work and that they worked in a friendly environment. What has improved since the last inspection? What they could do better: The home had admitted a new service user recently under the age of 40. The manager was informed that she is operating outside the granted registration conditions. An application has been made to CSCI for a variation in registration to include this service user to be considered. The inspector spoke at length with the new service user, whose brother is a resident in the same home. She said that the home can meet her needs and she is happy to be near her brother. Her father was present at the time and said that the home was meeting his daughter’s needs and he was very pleased that she had been admitted to the home. The Manager assured the inspector that all needs were being met by the home. The inspector received very positive comments in writing from the family. The Manager was informed that the application would be considered. Two recommendations were made during the inspection: • • The Manager is to consider a shelf to be put up in the ground floor sluice room to accommodate storage. The Manager is to consider installing ceiling hoists for those service users with high dependency needs. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 7 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. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 8 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 Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 9 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) 3,4,5 Service users are informed of the home of their choice, are able to assess the quality, suitability and facilities of the home and know these will meet their needs. EVIDENCE: Pre admission assessments were evidenced, and service users stated that they were either assessed in their own homes or in hospital. Some service users said that their families were included in the choice of home. They visited the home before admission. Service users were able to have a month to decide whether they would become a permanent service user, and family were included in all decisions if the service user wished them to be. This month trial could be extended if necessary. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 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) 7,8,9,10,11 There is a clear and consistent care planning system in place that provides staff with the information they need to satisfactorily meet the service users needs. The systems for administrating medication are good with clear and comprehensive arrangements in place. EVIDENCE: Care plans were evidenced to be clear and detailed and signed by the service user or family. They were updated as and when necessary and included wishes in the event of death, assessment forms, goals, nursing instructions, pressure area risk assessments, consent for influenza vaccination, daily report, falls risk assessment, critical illness wishes, manual handling risk assessments, consent for photograph to be taken, cot side risk assessment and consent for specific nursing procedures to be carried out. The medication policy was evidenced, together with samples of signatures of the staff administrating medication. Medication Administration Records evidenced were in order. All medication was stored correctly and CD medication recorded well. A comment received by the pharmacist stated: ‘I am perfectly satisfied that Oakcroft House operate to the highest possible standard for all pharmaceutical and clinical areas that I come into contact with.’ Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 11 All service users doors were closed during the inspection, and staff were observed to knock on doors before entering. Service users were able to have visits from friends and family in private in their rooms, and when the GP visited he saw them in private. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 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) 12,13,14,15 The service users were seen to experience a full life with opportunities to take part in varied activities. The meals in this home offer both choice and variety. EVIDENCE: During the inspection it was pleasing to note that service users were being offered varied activities. Service users had a demonstration on cake icing by the Activities Co-ordinator. Some were painting pictures, some knitting and others enjoying the company of other service users. One service user was receiving visitors in the activities room by his own choice. The Manager stated that other activities in the home include listening to music and talking books, crosswords, pre lunch sherry, mobile library, and a pianist comes in fortnightly to play the piano in the lounge. Service users could go on outings to garden centres, shopping and other places of interest. Some service users regularly go home to family on weekends. The monthly menus were evidenced and found to have variety, and well balanced. One service user said: ‘The food is great.’ And another: ‘The food is remarkable.’ Another service wrote in a comment card: ‘ if there is something I don’t care for, the Chef is most helpful.’ The meal at the time of inspection was roast pork with apple sauce and a desert of fruit and custard. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 13 The dining room was well furnished and looked clean and tidy. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 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) 16,17,18 The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. Service users were aware that they could inform the Manager when they had a complaint EVIDENCE: Service users were aware that they would inform the manager if they had a complaint. The Manager said that service users had a copy of the complaints policy. The complaints policy was evidenced and contained the telephone number and address of the CSCI. Service users were very complimentary of the home and said that they had nothing to complain about. Service users’ legal rights were protected, by having access to their own bank accounts and solicitors. Some service users had voted in the last General Election. The home has a policy on abuse and staff were trained in The Protection of Vulnerable Adults. When asked about abuse, what it was and what they would do if they saw a service user being abused, the staff answered correctly. Staff files were evidenced to have Criminal Record Bureau clearance before commencing employment. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 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) 19,20,21,22,23,24,25,26. The standard of the environment in this home is high, providing service users with an attractive and homely place to live. EVIDENCE: The home is very attractive with well - decorated bedrooms and communal rooms. The service users are able to access a sensory garden to the rear of the house. The home has a large activities centre, which acts as a social and craft centre for the service users. One of the home’s cats was very much in evidence during the inspection and it was observed that the service users enjoyed having a pet in the home. The home has two cats. It was evidenced that risk assessments had been made of the home and Fire Risk Assessment was in place. Hoists, Parker baths, wheelchairs and various walking aids used by service users and had been routinely serviced or checked. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 16 Service users were able to bring with them small items of furniture, ornaments, photographs and pictures to display in their rooms. One Service user had a picture of the horse that she used to ride, displayed on her bedroom wall. This service user said that she was very pleased with her room, which had a balcony and a view over the garden. The home was exceptionally clean with attractive communal rooms and garden. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 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) 27,28,29,30 The Manager is supported by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The home has a stable and well - trained staff. Training received recently included Fire Safety, Manual Handling, Health and Safety, Food Hygiene, First Aid, Protection of Vulnerable Adults and Infection Control. Fourteen staff had achieved NVQ level 2 and eight had achieved NVQ level 3. The home has it’s own Training Coordinator who is also an NVQ Assessor. Staff receive basic induction and are shadowed for two to three weeks by another staff member. Recruitment files were evidenced and found to be robust. All necessary documentation was in place including two written references, work permits and CRB clearance. All employment files sampled contained terms and conditions of service. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 18 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) 31,32,33,36,37,38 The Manager is supported by a dedicated, well supervised team who are protected by the home’s policies and efficient record keeping. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: Service users and staff were very complimentary about the Manager and how the home was run. The Parkinson’s Disease Specialist Nurse commented: ‘ I have found all aspects of care and management at Oakcroft House very good indeed. They have managed some of my complicated PD patients expertly and with compassion and I feel I have a good working relationship with them whenever any of my patients are resident.’ The Coniston Dental Practice wrote: ‘Very well run home which should be the benchmark for care. I have worked with them for 25 years and am delighted to continue.’ Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 19 It was evidenced that staff received formal supervision at least 6 times a year, which covered, all aspects of practice, philosophy of care in the home and career development needs. Care plans, risk assessments, pre admission assessments, supervision and recruitment records were evidenced during the inspection and found to be comprehensive, clear and up to date, with all the relevant information included. Care plans were evidenced to be signed either by the service user or their family, and kept securely. Training files showed that staff had received training in Health and Safety, Control Of Substances Hazardous to Health, and Food safety. They had also received training in The Protection Of Vulnerable Adults. Safety checks were made on Gas Appliances, Chlorination, Fire Alarms, Lift Maintenance, Water temperatures and a general building risk assessment made. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 20 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 x x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 4 STAFFING Standard No Score 27 4 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 3 3 3 3 x x 3 3 3 Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 21 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 Regulation Requirement Timescale for action 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 22.(7 22(4) Good Practice Recommendations It is recommended that the Registered Person provide a storage area in the ground floor sluice. It is recommended that the Registered Person consider ceiling hoists for service users with high dependency. Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Oakcroft House H58_s17629_Oakcroft House_v219048_010605_stage 4.doc Version 1.30 Page 23 - 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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