Inspection on 03/05/05 for Oakfield

This inspection was carried out on 3rd May 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

Oakfield 11/03/08

Oakfield 22/08/06

Oakfield 13/04/04

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

CARE HOMES FOR OLDER PEOPLE Oakfield 30 Oakfield Road Ashtead Surrey KT21 2RD Lead Inspector Mr D Ramdas Unannounced 3rd May 2005 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. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Oakfield Address 30 Oakfield Road Ashtead Surrey KT21 2RD 01372 272540 0208 642 7729 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) Trilodge Ltd Mr C Aristidou Care Home 24 Category(ies) of MD - Mental Dissorder 60 years and over (24) registration, with number of places MD(E) - Mental Dissorder over 65 (24) Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service may five(5) named service users, below the age of 60 years, under the category MD Date of last inspection 7th September 2004 Brief Description of the Service: Oakfield is a care home that provides nursing care for 24 people with mental disorder. It is located in a residential area close to the village of Ashtead in Surrey. The home can accommodate twenty four service users both male and female. The accommodation is on three floors which can be accessed via a lift. The accommodation comprises of two communal lounges, bathrooms and shower rooms, a kitchen, a laundry, a designated smoking area, an office and a staff room. The home has a lift which is used by some service users. There is a well maintained back garden with mature trees. There is also a large raised patio area. The home has parking to the front of the building. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over a period of 5 hours. A partial tour of the premises took place and staff and service users were spoken to also records were inspected. Seven staff on duty and six residents were spoken to. What the service does well: What has improved since the last inspection? What they could do better: The home could improve one of the bathroom areas by replacing the Parker Bath with a new one and also replacing the flooring. This would improve the bathing facilities for service users. The home must check the central heating system and the lift and ensure there are up to date service records so that the environment remains safe for service users. The home must also repair the fence in the back garden to ensure the privacy and safety for service users. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 Page 6 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. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 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 Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5. Service users and prospective service users were provided with details of the services the home provides enabling an informed decision about admission to the home. EVIDENCE: The home had a Statement of Purpose that contained information about how the home operated. It was reviewed and updated in Sept 04 by the Registered Manager of the home. Some of the information in the statement of purpose indicated how the home would meet the needs of a service user and what the service user can expect, such as, aims and objectives, the philosophy of care, fees charged, activities provided and how the home would be managed. The home also had service user guides that were up to date. The inspector found both the Statement of Purpose and Service Users Guide to be written in simple language. The Statement of Purpose was printed in pink colour and the service user guide in orange colour in order to avoid confusion. The inspector found evidence of good assessment procedures and also evidence that the health care needs of service users are being met. One service user who was admitted two months ago said, he was very happy with the way he had been transferred and he had lots of information about the home before he moved there. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 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 standard(s) 7,8. The health and personal care needs of service users are well met with evidence of multi-disciplinary working taking place. EVIDENCE: Service users care needs were appropriately met. For example, one service user who had been admitted recently had a key worker who was a qualified nurse. The service user assessment was up to date. Where the service user was identified as having low weight, a nutritional screening assessment was completed. The shift leader stated, the service user would be referred to the community dietitian. The service user also had a GP and a community psychiatrist. A Waterlow pressure area assessment was completed and a body map would be used to chart any pressure areas. The inspector had a discussion with staff and they indicated they understood the service user needs and were able to meet them. The inspector met with the service user who was smiling and appeared happy and comfortable. The shift leader stated, the service user is due to have a care plan review in the next three months. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 Page 10 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) 15 The meals in this home are good offering both choice and variety. EVIDENCE: The home employed a cook who had a City and Guilds qualification in catering. The inspector was shown the kitchen area and other food storage areas that appeared clean and hygienic. The menu plan that was viewed was on a five week rota basis. The plan reflected variety and choice. The inspector observed meals being taken in the dining room and were relaxed and informal with plenty of interaction between staff and service users. During the inspection, one service user gave the cook a card asking for a christmas pudding to be made, another service user stated, that the cook makes her a large omelette because she does not eat fish. Another service user said, he had been putting on weight. He commented, the food was good and he gets a choice. Environmental Health Officers visited and inspected the kitchens on 10. 3. 05 and made two recommendations. The shift leader stated this would be acted upon. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 Page 11 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 complaints system that is understood by staff and there is evidence that some service users are able to use the system to get their views listened to and acted upon. EVIDENCE: The home had a Complaints Policy that was clearly written and was available to staff. The staff stated that they knew where the policy could be found. They also described how they would handle a complaint made by a service user or a relative. The home had a complaints book but no complaints had been recorded. Staff advised that no complaints had been made since the last inspection. The home had used advocacy and befriending schemes. The inspector was informed an advocate was involved in supervising the transfer of one service user to the home. Another service user has someone who visits her and took her out into the community. There was a Whistle Blowing policy. The inspector noted that five staff had been booked to attend the Surrey Multi-Agency protection of vulnerable adults training on 5. .6. 05. A booking form had been completed. Three service users spoken to stated they would make any complaint to the manager. One stated, she had nothing to worry about and feels safe. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 Page 12 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 is good providing service users with an attractive and homely place in which to live and receive nursing care. EVIDENCE: On the day of the inspection, the home was found to be clean and tidy. The décor was of a good standard and the furniture and fittings were of good quality. Bedrooms were found to be well presented and personalised with family photographs, pictures, cards and ornaments. One service user said she liked her bedroom because she could have her own furniture, another stated, she was allowed to keep her pets in her room. The inspector found a Parker Bath in the bathroom on the ground floor that needed to be replaced as well as the flooring. The shift leader advised a bath had been ordered. The radiator in Room 8 was found to be making a noise. The shift leader reported that this was being looked at. There was no service record produced for the central heating system. The inspector also found the service record for the lift was out of date. During the inspection the shift leader contacted a gas company to come and look at the central heating system. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 Page 13 Outside, was a large patio area and the gardens were well maintained. Staff commented that in the summer months, a local gardener was employed to maintain the lawns. There was wheelchair access from the patio to the grounds. The fence in the garden had a large hole and needed to be repaired. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 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 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) EVIDENCE: This area was not assessed during this inspection. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 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 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) 32 The manager is well supported by staff in providing clear leadership throughout the home. EVIDENCE: On the day of the inspection, the registered manager was on annual leave. The shift leader and other staff on duty had a knowledge and understanding of the aim and purpose of the home. Staff reported, the home was well run and well managed. The manager was described as approachable, supportive and one who kept staff and service users informed of any changes or developments in the home. The inspector observed the home to have a happy atmosphere with plenty of interaction between staff and service users. On duty was a shift leader who was a qualified nurse, care assistants with NVQ qualifications, a domestic, and a cook all of whom had a clear understanding of their role and responsibilities. The home had an equal opportunities policy. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 Page 16 Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 2 3 3 3 2 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x 3 x x x x x x Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 Page 18 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 NMS 25 Regulation 23(2)(c) Requirement Timescale for action 01.06.05 2. NMS 19 23(2)(o) 3. NMS 21 23(2)(j) 4. NMS 38 23(2)(c) The registered person must ensure that the central heating system is maintained in good working order and that a copy of any service records be sent to the Commission. The registered person must 01.06.05 ensure that the fence to the rear garden is repaired in order to ensure privacy and safety for service users. The registered person must 01.07.05 ensure that the Parker Bath to the ground floor bathroom is replaced with a new one and that the flooring to the bathroom is replaced at the same time. The registered person must 01.06.05 ensure that the Stannar lift is serviced and that a copy of the service record be sent to the Commission. 5. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 Page 19 No. 1. Refer to Standard NMS 38 Good Practice Recommendations To consider putting in place a system to record the date and the time the kitchen is cleaned. This is line with good food hygiene practice. Oakfield H58_s13342_Oakfield_v220543_030505_stage4.doc Version 1.30 Page 20 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. 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