Inspection on 05/10/06 for Oakhaven - City of York Council

This inspection was carried out on 5th October 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 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

Oakhaven - City of York Council 03/10/07

Oakhaven - City of York Council 18/01/06

Oakhaven - City of York Council 05/07/05

Oakhaven - City of York Council 23/11/04

Oakhaven - City of York Council 27/08/04

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Hawkhills

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Oakhaven - City of York Council 144 Acomb Road York North Yorkshire YO24 4HA Lead Inspector Jo Bell Key Unannounced Inspection 5th October 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 Oakhaven - City of York Council DS0000034921.V313752.R02.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. Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakhaven - City of York Council Address 144 Acomb Road York North Yorkshire YO24 4HA 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) 01904 791599 01904 784 985 City of York Council *** Post Vacant *** Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2006 Brief Description of the Service: Oakhaven is a care home run by City of York Council and is registered to provide a service for 27 older people of either gender aged over 65 years who do not have any specialist requirements. Oakhaven was purpose-built approximately 50 years ago and is located within a short walk of Acomb Village centre. The accommodation is provided in single rooms on two floors. The upper floor is accessible via passenger lift. Structural alterations have been completed to create more open lounge space and additional toilets. Up to 6 day care places per day are available. The scale of charges currently range from £400 upwards. Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection took place on Thursday 5th October 2006. One inspector spent six hours in the home. A pre-inspection questionnaire was completed and comment cards from relatives and healthcare professionals were returned prior to the visit. The Home currently has a temporary manager in post, this should be resolved shortly. Service users commented positively on the good standard of care provided and the variety of activities available. The home has shortfalls in some health and safety areas and record keeping relating to mandatory training for staff. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 6 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 Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 not applicable) Quality in this outcome area is good. Service users have their needs assessed appropriately prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two pre-admission assessments were inspected, the hospital social worker had completed one and a care manager another, these were found to be comprehensive and contained information relating to activities of daily living, physical and social care needs. The care leaders generally carry out an initial assessment within a few weeks of admission. Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. Service user needs can be met in a dignified manner by the staff in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two plans of care were inspected, these had detailed care plans which highlighted the care needed for a particular individual. Though they were not regularly reviewed or evaluated. Risk assessments were in place for moving and handling and the prevention of pressure sores. Nutritional assessments should be carried out on all service users when they are admitted, however currently this only takes place when a need has been identified. One person was undernourished and the Home had liased with the GP and District Nurse who had developed their own dietetic assessment, the persons weight has now increased through good links with the community and care staff. During the visit a GP was spoken with who confirmed they had a good working relationship with the Home, care leaders are aware of how to contact other healthcare professionals including the chiropodist, dentist or optician. The Home report any incidents or accidents affecting service users through the Regulation 37 notifications, no serious issues have been raised. Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 9 The medication system was inspected, a policy is in place and the care leaders are responsible for administering medication, they have all completed accredited medication training, this was confirmed through their training files and in discussions. A medication round was observed and this was carried out in a dignified manner (during lunchtime). Two medication charts were inspected and whilst these were completed without omissions it was evident that a stock balance does not take place on a weekly or monthly basis. Many service users were prescribed paracetamol and there was no audit trail to confirm how many there should be in each box or whether one tablet or two tablets were administered at each medication round. This should be addressed. The controlled drugs were checked and found to be well maintained, a pharmacy audit had recently taken place and they suggested having a specific controlled drug cupboard. Staff take the temperature of the fridge on a daily basis, this contains eye drops and insulin. Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 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 the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. Service users are able to enjoy visitors, family and friends being welcomed to the home along with positive links with the community. The meals provided are adequate though more variety suitable to the client group would be beneficial. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an activities organiser who offers a range of activities both in the home and through organised trips. Service users have been to Burnby Hall Garden in Pocklington, Bridlington, and enjoyed trips into Acomb and York. The home raises money through events to hire a mini bus for trips. Activities in the home include entertainers, tea dances, bingo and dominoes. Service users interests are documented in their individual care plans. Day service users were spoken to and they confirmed there are a range of activities, many said they never get bored because there is always something to do. Staff were observed asking service users when they would like to go to the dining room for lunch, or what they would prefer to do, autonomy and choice is encouraged this was evident during the site visit. Visitors were observed in the home, the visitors book had family and friends detailed with a range of times attending. Links with the local community are forged through the church and community groups. Service users spoken with confirmed they can receive visitors either in Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 11 their own room or in one of the communal areas. Staff were observed treating visitors with dignity and respect and offering them a drink when they arrived. Meals are provided through a contract with the local hospital. Breakfast and evening meals are prepared on the premises. One service user had weetabix and bacon sandwiches for breakfast. The meals vary, some service users really enjoyed them, this was observed at lunchtime where baked ham and vegetables with chocolate sponge and custard was served. A copy of the menus was supplied in the PIQ and it was evident that not all food was suitable for this client group, previously a cook has been employed to prepare all the food on the premises, however, it is a policy used throughout the CYC homes that the hospital provide the catering. This should be reviewed. The kitchen was examined and found to be clean and tidy, fridges were stocked with deserts, eggs, milk and bacon. The store rooms were in good order. Service users are given a choice of food a few days before it is served, there are a range of dining rooms which can be used these are well presented with comfortable chairs, material table cloths, pot crockery and plate guards are used when needed. Eight service users were spoken to over lunchtime they all commented positively on the dining areas and confirmed they could eat in one of the communal areas or in their own room. The home can cater for service users who are diabetic, require soft or pureed diets or with special nutritional needs. Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. Service users are treated with dignity and respect and their concerns are listened to. Staff do need to have a greater awareness of adult protection procedures to ensure service users are not put at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home have a complaints procedure in place though the copy available was from 1994, a complaints book was available and no issues have been identified since February 2006. Service users spoken with confirmed they could take any concerns to the person in charge or one of the care leaders. Eight service users were involved with general discussions and they all had positive comments to make. Staff had an understanding of the types of abuse service users could be exposed to, though a greater awareness of the procedure and the implications in practice is clearly needed. A copy of the multi agency document was available and the staff who have undertaken an NVQ in care confirmed they have had some training in this area. Awareness training does take place for all staff, however currently this is not mandatory. Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. The home has a pleasant environment which is well maintained and clean and tidy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Infection control procedures were in place with staff having a good understanding of handwashing techniques and how to manager soiled laundry. The laundry was clean and tidy and the member of staff working there confirmed she had attended infection control training recently. Service users were observed wearing clean and nicely presented clothes, some handwashing takes place for delicate clothes and the key worker is responsible for replacing clothes once they have been washed and ironed. All areas of the home smelt clean and fresh. The environment had a welcoming feel with corridors painted in attractive colours which service users liked. Two service users rooms were inspected and these were clean, tidy and well maintained. The home use the City of York Council repair centre for any maintenance issues that need dealing with. Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. Staffing levels are adequate with staff being appropriately trained. Generally service users are protected through the home’s recruitment procedure though there are areas that need improving. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The temporary manager is supernumerary. During the visit there were twenty six service users and a further six day care clients. One care leader and two care staff were on duty during the morning supported by general assistants. Though, during the afternoon this was reduced to one care staff with one care leader. This did not appear to be sufficient as the care leader has responsibilities for the day to day running of the floor which makes it difficult for one carer to meet the needs of the other service users even with support form the general assistants. This should be reviewed as this was also commented on by individuals who completed comment cards prior to the visit. Some staff have completed their NVQ Level 2 or equivalent though the home have not reached 50 . Induction training does take place and records were available to confirm this. Recruitment practices were discussed with the temporary, part time manager. Service users are generally protected through the Home’s recruitment procedure as CRB and POVA checks are carried out on staff along with two written references. However, some of the information was stored at a central office i.e. part of the application form, and the CRB information form did not Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 15 confirm that POVA checks had been carried out, though the Manager gave assurances that this always takes place as part of the CRB check. Two staff files were checked and on one occasion one of the references gave no information apart from the dates when the person was employed. The Home must ensure sufficient evidence is obtained from references prior to offering a potential employee a job. The files need to be kept in good order with clearer guidance as to what information should be stored at the Home. Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is adequate. Service users needs are generally met though outcomes regarding quality assurance need to be improved which should be implemented when a permanent manager is in post. Aspects of health and safety also need to be addressed. This judgement has been made using available evidence including a visit to this service EVIDENCE: Currently there is no registered manger at the home, a manager from another CYC home is working 2 days per week at this home until a permanent member of staff is appointed (very shortly). Staff commented that an effective manager is needed to ensure the smooth running of the service. However, the temporary manager is waiting to be registered by CSCI and he has plenty of experience in caring for older people. Quality assurance in the home was discussed, currently there is no specific annual development plan or quality assurance document in place. Service Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 17 users are happy to discuss any issues informally but no formal surveys/questionnaires are sent out and relatives/residents meetings do not take place. The temporary manager was aware of this and has started to develop a system to incorporate these aspects. There was no evidence that care plan, medication or accident audits take place. However, this may be due to the fact that there is no permanent manager in place. This area needs addressing to ensure views and opinions regarding care practices, food and accommodations are heard and understood. Two service users accounts were checked. The money was stored in individual envelopes and records pertaining to these tallied with the amount of money stored. Receipts are available and the administrator is responsible for maintaining and storing the money securely. Currently no valuables are kept for service users, though some have asked that money be collected by the administrator following discussions with the service user and their family. Two service users were spoken with who said they had access to their pocket money for hairdressing, newspapers or toiletries. Health and safety in the home was inspected, a tour of the premises took place, Three water temperatures were tested these were all found to be higher than the expected range, 44 degrees, 44.5 degrees and 45.5 degrees. Details of previous water temperatures were not available, the home must ensure temperatures are regularly recorded and action taken where temperatures are too high to ensure the risk of burns and scalds are reduced. Fire safety was discussed and whilst fire drills take place and previous fire assessments have taken place there was insufficient evidence to confirm that fire training has taken place on a regular basis. Staff spoken with discussed the mandatory training they have received, variable responses were obtained. Records checked showed some staff had not received moving and handling, infection control or infection control training. The records were either incomplete or the training had not taken place. This should be addressed to ensure staff are trained to carry out their roles effectively. Health and safety certificates were randomly checked and these corresponded with the information in the preinspection questionnaire. Service users spoken with had no concerns regarding health and safety. Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 1 Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 16 Requirement Timescale for action 05/10/06 2. OP38 13 Two written references must be obtained which contain enough information to determine the applicant’s suitability for employment. POVA checks must be recorded along with the CRB check Staff must attend mandatory 05/11/06 training on a regular basis, and records must be kept to evidence this. Water temperatures must be recorded on a frequent basis and appropriate action taken when temperatures are too high 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. Refer to Standard OP7 Good Practice Recommendations Care plans need to be reviewed on a regular basis Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 20 2. 3. 4. 5. 6. 7. 8. 9. OP8 OP9 OP15 OP18 OP27 OP31 OP33 OP28 Nutritional assessments should be carried out on all service users. Stock balances of medication should take place on a monthly basis. A review of the range of meals should be undertaken. Training in the adult protection procedure should take place for all staff Staffing levels should be reviewed to ensure there are enough care staff on duty A permanent manager should be employed An annual development plan should be implemented 50 of care staff should achieve an NVQ Level 2 or equivalent Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 21 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oakhaven - City of York Council DS0000034921.V313752.R02.S.doc Version 5.2 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!