Inspection on 30/11/06 for Oakhaven Care Home

This inspection was carried out on 30th November 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

Similar services:

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Abbey The

Hawkhills

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Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Oakhaven Care Home 213 Oakwood Lane Oakwood Leeds West Yorkshire LS8 2PE Lead Inspector Sean Cassidy Key Unannounced Inspection 30th November 2006 09:30 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 DS0000066834.V319150.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. 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. DS0000066834.V319150.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakhaven Care Home Address 213 Oakwood Lane Oakwood Leeds West Yorkshire LS8 2PE 01422 345666 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) Eldercare (Halifax) Ltd Mrs Barbara Ann Holdgate Care Home 24 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (24) of places DS0000066834.V319150.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 18 October 2005 Brief Description of the Service: Oakhaven is a twenty four bedded home for elderly people situated in the north of Leeds. The house was built in Edwardian times as a family home and still retains many of the original features. Over the years various alterations have been made to make the home more accessible. There is a tastefully built extension to the rear, offering single, ground floor, en-suite accommodation. All other bedrooms are located on the first and second floors, the first floor being accessed via a chair lift or staircase. There is one shared room with separate lounge and bathroom where a couple may live a little more independently should they so choose.All bedrooms within the home are pleasantly decorated and carpeted and can also be colour co-ordinated should service users so choose.All meals are prepared and cooked on the premises. DS0000066834.V319150.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence in this report has included: • • • • A review of the information held on the home’s file since the last inspection. Information submitted by the registered provider in the pre inspection questionnaire. Information received from service users, relatives, staff and other professionals. An Unannounced visit to the home was conducted by one inspector and lasted eight hours. The majority of this time was spent speaking to residents, management, staff and relatives. The visit included a tour of the premises. A number of documents were examined which included care files, training files, recruitment files and health and safety details. What the service does well: The home ensures that residents are pre assessed prior to moving in. They are also provided with an opportunity to visit the home prior to this move. The service provides a warm, homely and friendly environment. Residents and relatives were quick to praise the staff team and found them very helpful. Positive comments were made about how the staff respect their privacy and dignity when providing the care package. Staff were observed to be very attentive to the needs of the residents. Relatives and friends are very much encouraged to maintain relationships at all times. A good standard of care documentation is used to identify and provide for resident care needs. The home is quick to communicate any changes in residents’ health to the appropriate health professionals and relatives. DS0000066834.V319150.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Improvements must be made with providing residents and their families with up to date information about the home. Although the care plans and assessment documentation has improved, more work is needed to show that the resident or their representative has been involved with agreeing to the care planned. Improvements are needed with providing a more structured programme of activity for residents. Particular attention must be paid to Dementia when developing this service. The care staff must receive appropriate training in adult protection. The numbers of domestic staff must be reviewed to ensure they are appropriate to the needs of the home. The roles of the domestic workers and carers must be clearly defined. More carers must be trained to NVQ Level 2 standard or above. The induction for new care staff must meet the recommendations highlighted by Skills for Care. Tighter recruitment checks are needed to ensure residents are thoroughly protected. The manager must ensure that she has attained training in care that is equal to NVQ Level 4 or above. The home must develop an annual quality improvement document that provides residents and others with information as to how the home maintains quality care and how it attempts to further improve care. Infection control techniques and training must be reviewed to ensure residents and others are appropriately protected. DS0000066834.V319150.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. DS0000066834.V319150.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection DS0000066834.V319150.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information available helps prospective and existing residents make an informed choice about their care. Residents are assessed prior to admission so that the home can make sure they are able to meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide have been redesigned to reflect new changes as a result of the change of ownership of the home. Residents are not yet provided with the new Service User Guide. The manager said there are a still a few changes that have to be made before they can be given out to all residents. Assurances were given that the document would be ready soon. DS0000066834.V319150.R01.S.doc Version 5.2 Page 10 The resident care files showed that the home assessed the prospective residents to ensure they could meet their needs. These documents were robust and allowed the home to get sufficient information to make their decision on admission. Residents spoken to confirmed they visited the home before they made the decision to take a room. Relatives spoken to confirmed they had also ample opportunity to discuss any issues they had regarding the services offered within the home. DS0000066834.V319150.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home works hard to ensure the health, personal and social care needs of the individual residents is maintained. Residents and relatives are confident that the home upholds their privacy and dignity. EVIDENCE: The care files of three residents were examined during the inspection. Each resident has recently undergone a thorough reassessment of his or her care needs. For each care need identified a plan of care had been developed. These care plans contained a good standard of detail needed to ensure the care needs of the residents could be met. They were very person centred in their approach and were easy to understand. Staff spoken to were aware of the care needs of the individual residents they were caring for. DS0000066834.V319150.R01.S.doc Version 5.2 Page 12 Care plans were reviewed on a monthly basis and changes to care were highlighted when identified. Not all residents or their relatives are involved with developing the care plans and risk assessments. This was confirmed through reviewing the documentation and speaking to people during the inspection. The care files showed evidence that the home tries hard to ensure their health care needs are met. Risk assessments are carried out for all residents in areas such as nutrition, falls, pressure area care and moving and handling. These were all reviewed monthly. All residents are weighed monthly and there was a clear evidence trail to show other health care workers were involved when needed. The district nurse visiting the home said that the staff group are ‘quick to respond to changes in residents care needs.’ Residents and relatives spoken to said that they were happy with the way the home ensured that other professionals such as the optician, dentist and chiropodist were involved in their care when needed. The care records showed these visits were recorded when they took place. The medication charts reviewed showed that overall, there was a good standard of medication administration within the home. The medication charts for three residents were examined. One irregularity was identified and the manager gave assurances it would be looked into as a matter of priority. There is a robust medication policy in place that includes guidance for using homely remedies and self-administration of medication. Residents and relatives spoke highly of the staff group. ‘They can’t do enough for you,’ ‘they are very helpful when you need their assistance. They are very responsive.’ The staff were observed to be courteous and respectful at all times. Residents and relatives spoken to said that they felt their privacy and dignity were upheld in the home. DS0000066834.V319150.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do not benefit from a structured and robust system for providing for their recreational and social needs. The home provides a very warm and welcoming environment for visitors. Residents enjoy the open visiting hours. Residents and their relatives are happy with the standard of food provided by the home. EVIDENCE: The new care plan documentation allows staff to make a record of what the interests, hobbies and social activities of the residents are. These were not always filled in. Some residents said they had a good deal of independence and that they were able to leave the home if they wished. This was confirmed in the care files and by talking with residents and the staff. There are no strict routines set by the home and evidence was found to show that a relaxed DS0000066834.V319150.R01.S.doc Version 5.2 Page 14 atmosphere was promoted. Music is used regularly and peoples likes and dislikes are taken into consideration. Relatives said that visiting times were very relaxed and that staff were very welcoming at all times. The district nurse also confirmed staff were welcoming. She also stated that staff have a good knowledge of the care needs of the residents when you ask for it. A poster is displayed that tells everyone what activities are planned for the week. Residents and relatives spoken to said that they did not regularly take place. A number of comments were made about the provision of activities within the home. “ The stimulation of individuals living here could be improved.” “There seldom appears to be anything much going on for residents in way of activity.” “There isn’t much activity provided here. I enjoy watching sport but I don’t get much opportunity.” Both the manager and staff acknowledged that this is an area that needs improving. They have recently advertised for the position of an Activities Coordinator. Residents confirmed that the home encouraged them to bring in their own possessions wherever possible. This was evidenced when residents rooms were inspected. The lunchtime meal was observed and was found to be an unhurried social event. The tables were well presented with appropriate condiments in place. Residents and relatives said they were happy with the standard of food provided by the home. There is a menu displayed on the wall and they are asked in the morning what they would like for their dinner. A choice is provided and some residents said that they could have something different if they didn’t like what was on the menu. The staff on duty helped residents who needed assistance with their meals. This was performed in a respectful and dignified manner. DS0000066834.V319150.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides clear information on how to make a complaint about the service. Not all staff are aware of their responsibilities with regards to adult protection. EVIDENCE: The complaints procedure is displayed in the home for all to view. Residents and relatives confirmed that they were aware of how to complain and who to complain to. All were comfortable with being able to complain and were also confident that the complaint would be investigated correctly. The home has an adult protection policy in place that helps staff to be more aware of issues that are relevant to this subject. There was no clear guidance available to help staff make an appropriate referral to the appropriate authorities if they needed to. Not all staff spoken had an understanding of adult protection issues or how to deal with an incident if it happened. The records seen showed that not all staff have received appropriate adult protection training. DS0000066834.V319150.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a good standard of comfort for its residents. Residents and their relatives feel that the redecoration plan already implemented in the home is improving their environment. EVIDENCE: Residents, relatives and other visitors said that this home is very welcoming and homely. The décor in some areas was acknowledged as being outdated and in need of redecoration. An improvement programme to improve the standard of décor within the home has commenced. One bedroom has been completed to a good standard and another is in the process of being completed. The manager said there was a commitment from the organisation to redecorate all resident bedrooms. DS0000066834.V319150.R01.S.doc Version 5.2 Page 17 The redecoration of the main lounge at the front of the home was nearing completion. This had been done to a good standard and received quite a lot of compliments from residents, relatives and staff during the inspection. Discussions were held with the manager regarding the suitability of the environment for residents with dementia. A number of staff have recently undergone a distance-learning course in Dementia Awareness. They are also enrolling the remaining carers onto this course. It was acknowledged that the environment could be more suitably adapted to assist the resident group with dementia. Residents and relatives said that they thought the standard of cleanliness in the home was good. Laundry facilities are provided and those spoken to gave good feedback as to the standard of the service. DS0000066834.V319150.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit more if the home provided a more thorough recruitment process and training programme. EVIDENCE: Residents and relatives spoken to were happy with the numbers of staff the home normally has on duty. Two relatives said the staff always seemed to have time to attend to the needs of the residents when they needed assistance. The staffing rotas were seen and these showed that the same levels of staff are maintained throughout the coming weeks. The manager said that there is an internal bank system for covering outstanding shifts. The staff were confident that the care needs of the residents were being well met and that the numbers of staff on duty were correct. The manager confirmed that care staff carry out domestic duties during the course of their working day. This takes them away from their caring role when performing domestic duties. It was also identified that not all staff have been trained in DS0000066834.V319150.R01.S.doc Version 5.2 Page 19 areas such as infection control and the Control of Substances Harmful to Health (COSHH) This places residents at possible risk. The recruitment files of three newly recruited staff were looked at. The manager agreed that the recruitment process was not as thorough as it should be. The references were not obtained prior to a carer starting work. One member of staff who worked with vulnerable adults in a previous role had not had an appropriate reference obtained from that service. The home has a programme in place that is aiming to ensure at least 50 of the staff group have been trained to NVQ Level 2. Other training is being provided that cover areas of resident need. The training provision was not structured and robust. Not all staff were receiving training in the areas of resident care need. The manager said that the home has recognised the need to change the induction programme to ensure this complies with the recommendations made by the Skills for Care organisation. This will benefit the resident group. DS0000066834.V319150.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall evidence shows the home is being well managed. This could be further improved if the manager received the required training. EVIDENCE: The manager and staff have recently undergone a change of owner. Those spoken to have had difficulties during this process but they felt that it was relatively well managed. The care staff have spoke highly of the manager during this process and said they felt well supported. The manager has not yet completed Level 4 in care. She recognises the need for this and the benefit to DS0000066834.V319150.R01.S.doc Version 5.2 Page 21 residents as a result of the qualification being obtained. A commitment was given to complete this training in the near future. Two relatives said that they felt the change in ownership had been managed well and had not caused any difficulty for them. Staff feel well supported by the management team. Relatives, residents and staff said they feel comfortable approaching the manager with any issues. The home manages the finances for some residents. The records were seen and were found in order. Receipts are kept for all transactions that are made. The manager uses a number of quality tools in an attempt to maintain and improve standards. Residents do not have access to this information and are therefore not aware of the methods that are used to improve quality. The manager gave assurances that they are working on developing a format to present to residents. Staffs spoken to were aware of the fire procedures of the home and regular training is provided. A good manual handling awareness was also identified and training is also provided in this area. A number of health and safety issues were brought to the attention of the manager. These included, poor infection control techniques used by the domestic staff; the use of communal towels and soaps in the toilets and bathrooms and the radiators without guards. DS0000066834.V319150.R01.S.doc Version 5.2 Page 22 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 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 2 DS0000066834.V319150.R01.S.doc Version 5.2 Page 23 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 2 Standard OP1 OP7 Regulation 4,5 15 Requirement All residents must be provided with an up to date copy of the Service user Guide. The registered person must ensure residents or their representatives are involved with developing the care plans and risk assessments. The registered person must ensure that the residents are provided with suitable activities and interests. Particular attention must be given to residents who have dementia dementia. The home must ensure all staff receive appropriate training in adult protection. (This requirement is outstanding from the previous inspection) The home must ensure that there are suitable numbers of domestic staff on duty. The registered provider must ensure at least 50 of the staff group are trained to NVQ Level 2 or above. The registered person must ensure a thorough recruitment DS0000066834.V319150.R01.S.doc Timescale for action 28/02/07 28/02/07 3 OP12 16 28/02/07 4 OP18 13 31/03/07 5 6 OP27 18,19 18 31/03/07 30/04/07 OP28 7 OP29 19 31/12/06 Version 5.2 Page 24 8 OP30 12,18 9 OP31 9 10 OP33 24 11 OP38 13 process is followed when employing new staff. The home must provide an induction pack that is in line with the recommendations made by Skills for Care. The registered manager must obtain a recognised management and care qualification that is equivalent to NVQ level 4. The manager must develop an annual quality assurance development plan that is made available to the residents and other interested parties. The registered person must ensure service users are protected from the risk of infection. 31/03/07 30/04/07 31/03/07 28/02/07 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 OP19 OP18 Good Practice Recommendations The home environment should be reviewed and adaptations made to further assist those residents in the home with dementia. The home should develop and display guidance for staff on how to make an adult protection referral to the relevant authorities if the need arose. DS0000066834.V319150.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 DS0000066834.V319150.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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