Inspection on 31/05/07 for Oakcroft House

This inspection was carried out on 31st May 2007.

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 03/10/05

Oakcroft House 01/06/05

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 HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Oakcroft House Oakcroft Road West Byfleet Surrey KT14 6JG Lead Inspector Vera Bulbeck Unannounced Inspection 31st May 2007 09:45 X10029.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 DS0000017629.V335322.R01.S.doc Version 5.2 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 and Care Homes for Adults 18 – 65*. 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. DS0000017629.V335322.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakcroft House Address Oakcroft Road West Byfleet Surrey KT14 6JG 0113 381 6100 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) www.bupa.com BUPA Care Homes (BNH) Limited Miss Vivien Rosemary Traquair Grieve Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48), Physical disability (5), Physical disability of places over 65 years of age (5) DS0000017629.V335322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 48 beds providing nursing care for elderly people from the age of 60 years. 5 of these may be used for Physically Disabled people from the age of 40 either PD or PD(E). 6 of these may be used for (PD) Physically Disabled from the age of 40. Additionally one named service user aged 38 years of age, as per letter dated 9th March 2004; in the category physical disability may be admitted. Additionally one named service user aged 39 years, as per letter, 18th May 2005; in the category physical disability may be admitted. 3rd October 2005 Date of last inspection 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 home is currently registered for 48 persons. The original property has been altered to provide spacious accommodation for up to 40 persons who require nursing care. Up to six beds at the home are registered to provide nursing care for younger adults. There are thirty-six single bedrooms with en-suite facilities and two double bedrooms with an en-suite facility. The home has a well-maintained rear garden, of which a part of it has been made into a sensory garden for service users. There is a spacious nicely laid out patio area and the home has a conservatory, which is situated across part of the back of the home. There are car-parking facilities at the front of the property for a number of vehicles. The fees for the home are from £950.00 to £1050 00 per week additional charges apply for hairdressing, chiropody, physiotherapy personal items and a personal telephone line. DS0000017629.V335322.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs V Bulbeck, Lead Inspector for the service carried out the site visit. The registered manager was present for the inspection. There were thirty-seven residents currently living in the home. The inspector was informed one vacant place had already been taken and a new resident is to move into the home very shortly. The site visit was unannounced, which meant that visitors, staff and residents were not aware of the visit prior to it commencing. The inspector had the opportunity to speak with a number of residents who live at the home, and five relatives and visitors. The majority were very complimentary about the home and staff. The site visit was over a period of eight hours thirty minutes. A full tour of the premises was undertaken. Three care plans were observed, and the care provided for the three residents was also observed. There were eight care staff on duty in the morning, and two registered nurses. In the afternoon the staffing levels change, and are lower. A number of staff was spoken to and all confirmed the home operates well and the majority of staff stated the residents receive quality care. The staff was observed to be courteous and the general atmosphere within the home was relaxed and friendly. The inspector would like to thank the residents and staff for their co-operation and hospitality during the inspection. The residents living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report. What the service does well: Resident’s views are continually sought to improve the service the home provides. Regular meetings with residents are undertaken; the registered manager informed the inspector, staff are trained to listen and talk to residents to ensure residents views are being heard. The inspector was informed that a Customer Satisfaction survey was undertaken in December 2006, and a number of surveys were sent out. Comments received were good and any suggestions made by residents or relatives are taken seriously and action will be taken to make any necessary improvements. Further information regarding the homes survey is available from the registered manager. The registered manager stated that the comments received were helpful and has already taken some action to improve areas mentioned in the survey. DS0000017629.V335322.R01.S.doc Version 5.2 Page 6 The home has been presented with a cheque for the staff fund of £500.00 having achieved the highest number of trained staff (21) for the new Quest care planning, recently introduced into all BUPA Homes. The inspector spoke to a number of residents; all were complimentary towards the staff, regarding the care provided and the staff team. Residents living in the home appeared to be happy; they were well dressed and some stated they enjoyed their lunch on the day of the site visit. Lunch is served in the dining room, the tables were nicely laid the food was plentiful and appeared appetising and nourishing. Some residents informed the inspector they prefer to eat their meals in their bedroom. The inspector spoke with a number of staff on duty on the day of inspection; staff commented they feel supported by the registered manager of the home. The home was homely and welcoming, areas in the home were nicely decorated and furnished. Some residents had some items of furniture in their bedrooms, which they had brought into the home with them. There are two cats living in the home named Sophie and Sammy who have been residents for a number of years. The residents are very fond of the cats and the cats appear to receive a lot of attention from residents and staff. One resident in particuarly who spends a lot of time in bed requests one of the cats is taken to her on a regular basis. What has improved since the last inspection? What they could do better: Staffing levels need to be reviewed and particuarly in the afternoon when staffing levels are low in comparison to the morning shift. The Environmental Health Officer visited the home December 2006 and made a recommendation for the chefs out door clothing to be stored out of the kitchen storage area. At the time of the inspection the inspector observed this recommendation had not been attended to, clothes were hanging on the shelving. DS0000017629.V335322.R01.S.doc Version 5.2 Page 7 This was discussed with the manager who immediately requested the work to be undertaken by the maintenance person, as a matter of urgency. The work involved was dividing and changing the inside of a cupboard outside the kitchen area. The manager has informed the inspector since the inspection the work has been completed. 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. The summary of this inspection report can be made available in other formats on request. DS0000017629.V335322.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) DS0000017629.V335322.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Each resident is only admitted to the home following a needs assessment to ensure that the home can meet the resident’s identified needs. The home offers intermediate care, this area was observed on a residents care plan. EVIDENCE: A number of residents have been admitted to the home; since the last inspection and it was noted that pre assessments had been undertaken these documents were found to be well documented. The manager informed the inspector a service users guide has been provided to all residents and relatives. This was not checked on this visit. The DS0000017629.V335322.R01.S.doc Version 5.2 Page 10 registered manager stated the statement of purpose and the service users guide is reviewed on a regular basis to include any changes. The home admits residents requiring intermediate care, and the same procedure applies with regards to a pre assessment. On the day of inspection a resident informed the inspector that she is now well enough to return home. Preparation and planning with a relative for the resident to return home including services are in the process of being arranged. The home rarely has the capacity to admit a person needing intermediate care, as the home is generally full. DS0000017629.V335322.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10, 16, 18 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was documented in care plans. The homes policies and procedures are in place all staff sign to indicate they have been read and understood. EVIDENCE: Three residents care plans were sampled and there was evidence that resident’s health, personal and social care needs had been identified and DS0000017629.V335322.R01.S.doc Version 5.2 Page 12 assessed. Care notes are well documented and detailed the home has new care notes, which are used as a working tool. A copy of the care plan is kept in the nurse’s office. A number of risk assessments have been updated for all residents living in the home. Medication records were found to be well documented and a list of staff signatures was recorded on the file. There was a photograph of the resident on the MAR sheet. The qualified nurse on duty administers medication. All nurses have received up to date medication training. The registered nurse in charge maintains a weekly check on the administration of medication to ensure there are no errors. The qualified nurses undertake this practice. Storage facilities were appropriate. There are currently no resident’s who are able to self medicate. The residents spoken to confirmed that staff are respectful and they knock on the door before entering. Observation by the inspector was some residents and staff have a good rapport. Residents stated they discuss any worries they have with their family. However, a number of residents do not have family or friends, the inspector would advise management of the home to seek the services of an advocate for those residents. DS0000017629.V335322.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported and encouraged to maintain contact with family and friends. Meals are well balanced and varied with individual choices and preferences as well as special dietary needs catered for. EVIDENCE: The Majority of residents have contact with family and friends and the inspector had the opportunity to speak with five relatives on the day of the site visit. The inspector observed that a number of relatives and friends visit the DS0000017629.V335322.R01.S.doc Version 5.2 Page 14 home. Discussion with the families at the time of the inspection confirmed that some visit on a regular daily basis. It was also noted in the visitor’s book that there is a daily record of visitors to the home. Three relatives spoken to confirmed they visit daily. Any resident who moves into the home and does not have family or friends an advocate needs to be involved. A number of residents are subject to Power of Attorney. There is a planned activity programme, and there is a separate activity room. The inspector spoke with the activity organiser who confirmed the programme is varied and she also stated that she ties to encourage those residents who do not wish to be involved. A number of residents stated they enjoy the activities and there should be more available. Residents commented that the staff team are very good; one resident commented “the staff are so busy they hardly have time to talk”; this is particuarly during the afternoon. The meals served in the home were nutritional in content and well balanced. The chef is involved with the menu planning, and seeks the resident’s views. The menu of the day is displayed in various areas around the home for residents to see and all residents are informed of the menu. The chef was on duty at the time of visiting the kitchen and was able to demonstrate the procedures and the operation of staff working in the kitchen. Cakes are baked every day for afternoon tea. A number of residents require feeding and the inspector observed some staff feeding the residents this can be a long process as some residents eat slowly. Therefore, some residents have to wait if they ring their call bell during meal times. This was an observation and also a comment from a relative. The inspector observed fresh fruit in dishes in the kitchen and the registered manager and a relative confirmed that residents are able to have fresh fruit whenever they request. DS0000017629.V335322.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a simple, clear and accessible complaints procedure, which includes timescales for the process. All required policies and procedures are in place to ensure that residents are safeguarded from harm or abuse. EVIDENCE: There has been one recorded complaint in the home since the last inspection. The outcome or letters of the closure for the complaints were available in a file and found to be well documented. All residents are provided with a copy of the complaints procedure, which, is available to the residents and provided within the homes terms and conditions. All new residents are given a copy on arrival in the home. A copy of the complaints procedure is also clearly displayed on the wall in the hallway. The homes policies and procedures for the protection of vulnerable adults and a whistle blowing policy were in place and all staff have received the protection of vulnerable adults training. Staff on duty confirmed they had undertaken this training and were aware of the procedures. The home needs to request an DS0000017629.V335322.R01.S.doc Version 5.2 Page 16 up to date copy of Surrey Multi Agency procedures, the copy currently available in the home is dated 2001. . The homes policy reminders are distributed monthly by BUPA the folder is available in the staff room and all staff are required to sign to indicate they have read the policy and a copy of their involvement is placed on the member of staffs file. Residents are encouraged to vote and some have been registered for a postal vote. DS0000017629.V335322.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 26 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible and safe with a pleasant and homely atmosphere. EVIDENCE: The home was found to be clean and tidy; there are four full time domestics, and a full time head housekeeper, maintaining the cleanliness of the home and two full time laundry assistants working in the home. DS0000017629.V335322.R01.S.doc Version 5.2 Page 18 There are several areas around the home that have a nice homely touch and residents are able to enjoy the surroundings. All the bedrooms were nicely furnished and personalised by the residents. The home has a full time maintenance person who is also the health and safety person who is responsible for the regular checks on the fire safety of the home. He is also the homes trainer for all staff to attend regular fire training and to ensure the staff are meeting the homes fire safety policy and procedures. The maintenance person is responsible for the general up keep of the home and ensures the environment of the home is operating to a good standard. This also includes decorating bedrooms when necessary. The grounds are spacious and nicely cared for the home has a sensory garden, which is nicely situated and welcoming to the residents. Residents who are unable to use the garden unaided are invited to use the garden by the activity organiser. A drain was observed in the garden to need a cover fitted to ensure leaves and litter do not enter and block the drain. On the day of inspection the inspector was able to speak with a relative who informed the inspector that her son had been a resident in the home prior to his recent death. The relative stated she was very happy with the care provided to her son that she had purchased a tree to commemorate his stay in the home. The tree has been planted in an area that was enjoyed by her son at the time of his stay. DS0000017629.V335322.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30, 32, 34 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of the staff needs to be reviewed to ensure the staffing levels in the afternoons meets resident’s needs. The home has a comprehensive staff recruitment and training programme which, incorporates all areas needed to ensure, as far as reasonably possible, that residents are in safe hands at all times. EVIDENCE: The staffing arrangements during the afternoon shift include four care staff on duty and a qualified nurse on duty who undertakes administering the medication as well as writing care plans and other duties as required. There are currently thirty-seven residents between the three floors and a number of residents require two or more people for providing personal care and a number of residents require feeding. DS0000017629.V335322.R01.S.doc Version 5.2 Page 20 Several residents commented that at times staffing levels are low, and sometimes they have to wait a long time in the afternoon before their call bell is answered. Several relatives also commented about the lack of staff in the afternoon, and at times not able to find a member of staff. Staffing levels need to be reviewed, the inspector advised the management of the home to undertake a staffing matrix to ensure the staffing levels are sufficient to meet the residents needs, and to ensure the safety of the residents. The registered manager stated she would increase the staffing levels by one member of staff during the after noon shift, and this would be attended to immediately. Full recruitment procedures are being followed. All staff has been checked against the Criminal Records Bureau (CRB) and POVA checked before working in the home. Staff records were observed and found to be well documented, including contracts and terms and conditions. The majority of staff has received (POVA) protection of vulnerable adults training and further training is ongoing. The home has 50 of staff with NVQ Level 2 training and above, this includes fourteen staff have completed NVQ Level 2 and two staff are in the process of NVQ Level 2. Four staff has completed NVQ Level 3 and two staff are in the process of completing NVQ Level 3. Training has been identified as a priority. It was pleasing to note that the home has been awarded Quest documentation for care planning, with a cheque to the sum of £500.00 for the staff fund. The cheque was presented to the home for achieving its goal for staff training (twenty one staff trained). All staff are provided with a portfolio at the time of induction, which includes details of NVQ Level 2. It was identified at the time of the visit that the registered manager and all staff have attended cultural awareness training. The registered manager informed the inspector that she has booked to attend a course in June 2007 with a member of staff for equality and diversity training. Training will then be cascaded down to the staff team. DS0000017629.V335322.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37, 38, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s, benefit from an open, positive and inclusive management style. The home has a monitoring system in place that is based on seeking the views of the residents. DS0000017629.V335322.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager is competent and qualified to manage the home, staff were complementary and stated they feel supported and the registered manager has an open door policy, staff stated they are able to speak with the manager at anytime. One member of staff stated the manager is very flexible with staff and has a great understanding. Regular visits are undertaken by a designated person to check the home is meeting the required standards. A questionnaire (Customer Care Satisfaction) is sent to all relatives on a yearly basis, the last questionnaire sent out was in December 2006 details of the survey were available at the time of the inspection the inspector was able to see the report. Information regarding the survey can be obtained from the registered manager. A number of records were checked and were found to be well documented and details were filed appropriately. The certificate for the testing of Legionella was not available the registered manager and maintenance person stated that the company have already checked the water and a certificate will be issued in due course. Residents finances are managed mainly by relatives, two residents have power of attorney. These residents are provided with a sum of money for personal expenses, which is managed by the administrator of the home and the registered manager. The Environmental Health Officer visited the home on 18th December 2006 and the home was given a recommendation for outdoor clothes to be stored in a separate area away from the kitchen. This had not been addressed at the time of the inspection. The inspector advised the registered manager this must be dealt with as matter of urgency. The registered manager immediately contacted a person to change the layout of a cupboard outside the kitchen door to accommodate the clothes. The manager confirmed within a couple of days the work had been completed. Five comment cards were received from residents and comments were complimentary towards the management and staff. Some of the comments from residents: • • • • • Menu is repetitive lots of chicken sandwiches not enough variety Medication is sometimes late Staff do not always answer the call bell for a while DS0000017629.V335322.R01.S.doc Version 5.2 Page 23 • • Would like more choice of food • • Need more staff at weekends • The comments mentioned above are taken from residents feedback comment cards sent to the Commission for Social Care Inspection prior to the inspection and discussion with residents on the day of the site visit. The inspector received seven comment cards from relatives/visitors and some were complimentary towards the staff and management. The majority stated the care provided is excellent. Some of the comments were: • • • • • • • • • • • The home performs to the highest standard, staff are well trained and go the extra mile The activity organiser does an amazing job Would be nice if someone could read letters or a novel to residents Residents would benefit from a choice of meal at lunchtime Staff shortages at mealtimes and 4pm changeover period Shortage of staff at mealtimes residents requiring personal assistance have to wait for some time until lunchtime is completed • The comments mentioned above are taken from relatives/visitors feedback comment cards sent to the Commission for Social Care Inspection prior to the inspection. Three comment cards were received from the G.P medical team and the response was very positive. DS0000017629.V335322.R01.S.doc Version 5.2 Page 24 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 X 2 X 3 3 4 X 5 X 6 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 X 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 X 33 3 34 X 35 3 36 X 37 X 38 3 DS0000017629.V335322.R01.S.doc Version 5.2 Page 25 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. 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 3 Refer to Standard OP19 OP27 OP38 Good Practice Recommendations A cover for a drain to stop leaves from blocking the drain. To review staffing levels. To obtain certificate for the testing for Legionella. DS0000017629.V335322.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. DS0000017629.V335322.R01.S.doc Version 5.2 Page 27 - 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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