Inspection on 11/11/05 for Oakleigh

This inspection was carried out on 11th November 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

Oakleigh 11/09/06

Oakleigh 21/04/05

Oakleigh 13/10/04

Oakleigh 26/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Oakleigh Evelyn Gardens Godstone Surrey RH9 8BD Lead Inspector Deavanand Ramdas Announced Inspection 11th November 2005 10:00 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 Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 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. Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Oakleigh Address Evelyn Gardens Godstone Surrey RH9 8BD 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) 01865 854000 Anchor Trust Mrs Susan Eades Care Home 50 Category(ies) of Dementia - over 65 years of age (20), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (19), Physical disability (5), Physical disability over 65 years of age (5), Sensory impairment (5) Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. For those residents within the category PD, age range is 18-64 years, for all others the age range is over 65 years. 21st April 2005 Date of last inspection Brief Description of the Service: Oakleigh is a care home providing personal care for people with dementia, learning disability, physical disability and old age. The home can accommodate fifty people and is located in Godstone, Surrey close to public amenities. The accommodation is on three floors and divided into five units. Each unit has a lounge, dining area, a kitchen, bathroom, shower and toilets. Bedrooms are single with en-suite facilities. Meals in the home are cooked in the main kitchen that has food trolleys. The home has adequate laundering and sluicing facilities. Private parking is available to the front of the property and the home has a large garden that is private and secure with wheelchair access. The manager is Susan Eades and the provider is the Anchor Trust. Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out by one inspector over a period of six hours. A partial tour of the premises took place and service users, staff and visitors were spoken to. Documents and care records were inspected. The inspector would like to thank the manager, deputy, staff, service users and visitors for their contributions to the inspection. Feedback forms, comment cards and a CSCI business card were left at the home for information. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure a review is undertaken of staff training in relation to medications and any shortfall in training is addressed without delay to protect service users from any risk or harm to health. Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 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. Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 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 the following standard(s): 2,3,5&6. The arrangements for providing contracts to service users are satisfactory ensuring service users tenancy rights are protected. The systems for assessing the needs of prospective service users are satisfactory ensuring service users needs are identified. The arrangements for trial visits are satisfactory ensuring service users have the opportunity to visit and assess the home. EVIDENCE: The home has a policy and procedure for licence agreements that is attached to service users contracts. The manager stated contracts are offered to service users that are kept in the service user files. The inspector sampled contracts and noted they were signed and dated by the service user, manager and a witness/representative. The inspector noted an agreement was signed by one service user dated 1/7/03 to amend his contract and change the bedroom to be occupied. The home has a policy on needs assessment that was reviewed and updated in 2004. The manager stated needs assessment were carried out the senior care team. The inspector sampled the file of a service user on respite care and noted a needs assessment was completed by Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 9 the acting manager and signed and dated 27/10/05. A joint health needs assessment, a medical assessment summary, and an occupational therapy assessment was completed and signed and dated 14/9/05. The manager stated the home offered trial visits to give service users and relatives the opportunity to visit and assess the suitability of the home. The inspector noted this was reflected in service users contracts. The deputy manager stated the system of trial visits ‘worked well’ and remarked one service user who lived in another county had a trial visit before admission to the home. The manager stated the home did not provide intermediate care and this standard was not assessed. Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9&11 The arrangements for managing medications are unsatisfactory that pose a risk to the health of service users. The arrangements for dying and death of a service user are adequate ensuring service users are treated with sensitivity and respect. EVIDENCE: The home had a medication policy that was reviewed and updated in September 2005 and covered ordering, checking and administration of medications. The manager stated the home had a service level agreement with Boots that supplied all medications to the home. The inspector noted medications were stored in a locked metal cupboard secured to the wall in a designated room in each of the five units. The home had a main drugs room that had a metal cabinet secured to the wall to store stock medications. The inspector noted a fridge that had eye drops, insulin and creams. The temperature of the fridge had been checked daily and the records show readings were within normal limits. The inspector sampled medications recording sheets and noted they were dated and signed by staff. Medication Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 11 recording sheets had a recent photograph of the named service user. The inspector noted a bottle of laxative had a label to indicate the date it was opened. A senior care officer stated the medication system worked well because two people check it. The inspector noted the home had two named staff with responsibilities for medications. Staffs training records on medications were examined and the inspector noted the records were in need of updating. Some medication competency questionnaires had not been reviewed that was discussed with the manager and action has been required in respect of this matter. The home had a dying and death policy dated 2004. The manager stated the policy is under review and the title of the policy will be changed to End of Life Care. The manager commented Anchor Trust Specialist Team would be providing staff training. The inspector noted training was planned on the 7/12/05 and the manager, deputy and four senior care officers were booked to attend. The manager remarked the home had a visitor room with en-suite facilities that is used by families and friends who wished to stay and comfort a service user who is dying. The inspector noted the manager had a counselling skills qualification and she stated she provided support to staff involved in caring for the dying. The home had information on CRUISE, a bereavement counselling service that was available to relatives and service users. Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The meals in this home are good and offer variety and choice and catering for the special dietary needs of service users. EVIDENCE: The home has an experienced chef/manager who worked full-time and had responsibility for the management of three kitchen assistants. The inspector noted the kitchen was clean, organised and well equipped. The inspector sampled records and noted the home had a daily, weekly and monthly cleaning schedule that was up to date. It was noted an environmental health officer inspected the kitchen on the 1/9/05 and recommendations were made. The inspector noted appropriate management action had been taken. The chef/manager remarked she had attended a course on hazard analysis on the 19/10/05 and commented the course was useful and informative. The home had a planned menu that offered variety and choice. The inspector sampled the menu order sheet and noted it offered choices of meals and desserts. On the day of the inspection service users had a choice of scampi, chips and peas or breaded chicken cutlets with boiled potatoes, peas and gravy. Dessert was jelly and ice cream or fresh fruits and a choice of drinks was available during lunch. The inspector noted meals were well presented and mealtime was relaxed and unhurried. Staff supported service users appropriately using verbal and physical prompts. The deputy manager stated Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 13 the home kept a daily record of meals and comments made by service users that were sampled. One service user stated the spaghetti Bolognese was so nice I had it for dessert as well. Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17&18 The complaint process at the home is adequate ensuring complaints information is widely available to staff, service users and relatives. The arrangements for protecting service users rights are satisfactory ensuring service users legal rights are protected. The systems for safeguarding service users from abuse are satisfactory ensuring service users are protected from neglect and harm. EVIDENCE: The home had a complaint policy dated 2004. The inspector noted the complaint policy and complaint information was displayed in the foyer and in each of the units. The manager stated the home kept a record of complaints. The inspector sampled the records and noted the last complaint was made on the 14/10/05 and management action had been taken. During a meeting staff stated they were aware of the complaint policy and one service user stated she knew how to make a complaint. She commented she complained about the choice of cakes that has now improved. The manager stated service users rights are protected and remarked one service user finances are managed under the court of protection. The home has contact with age concern that act as advocates if necessary and the manager commented service users vote in local elections. The home has a whistle blowing policy dated 2004. The manager stated training in the policy is undertaken during induction and is covered under rights and responsibilities training. During a meeting staff stated they were aware of the whistle blowing policy and one resident Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 15 remarked I have been at the home six years and never heard a staff raise their voice. She stated she had no reason to make a complaint. Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19&26 The standard of the environment within this home is good providing an attractive and homely place for service users to live. The arrangements for hygiene are good ensuring the home is clean and pleasant for service users. EVIDENCE: On the day of the inspection the home was clean, well presented and free from mal odour. The gardens were tidy and accessible to service users and one service user stated she liked looking out of her window into the courtyard. The home operated a security system that was restricted to the entrance of the building and the inspector noted a senior care officer was present in the foyer. The home had infection control measures and staffs were observed to wash their hands regularly. Anti-bacterial hand wash, gloves and aprons were widely available throughout the home. The home had industrial washing machines, dryers and sluicing facilities in each of the units. The inspector noted the home had a contract for the disposal of waste and staff stated the standard of hygiene throughout the home was good. Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 17 Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29&30. The arrangements for staff training are very good ensuring service users are in safe hands at all times. The recruitment and vetting practices are adequate ensuring service users are safeguarded and protected. The arrangements for staff training are satisfactory ensuring staff are competent to do their jobs. EVIDENCE: The manager stated the home is committed to training and development of staff. She remarked sixteen staff had NVQ Level 2 in care and three were working towards the NVQ Level 2 qualification, one staff had NVQ Level 3 in care and five were working towards the NVQ Level 3 qualification and four staff had the assessor awards. The inspector sampled records and noted staff had completed their NVQ qualification. During a meeting staff stated the company provided good training opportunities and four stated they had the NVQ qualification. The inspector noted the home had exceeded standard 28 of the national minimum standard as it had achieved more than 50 care staff with NVQ Level 2. The home had a policy on the recruitment and selection of staff dated 2002. The inspector sampled recruitment files and noted they contained completed application forms, references, terms and conditions of employment, a recent photograph of the employee and a health assessment. The inspector noted the home had information on police checks that was kept in a separate file and up to date. Recruitment files were kept in the manager’s office in a locked cabinet and the files were well organised and well presented. The home had a policy on induction dated 2002. The manager stated the home had revised the induction pack based on skills for care specifications. The inspector Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 19 sampled induction files and noted a staff that joined the company on the 19/9/05 had a personal training record that was dated and signed. One staff stated she had a three-day induction and shadowed a senior staff for two weeks as part of her induction programme. The inspector noted staff were allocated a supervisor for the period of their induction and the home had a training area, training aids and video’s on challenging behaviour, dementia, abuse and health and safety. Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35&36. The arrangements for managing the home are satisfactory ensuring the welfare of service users are safeguarded and protected. The systems in place for quality assurance are adequate ensuring service users, relatives and staff are consulted and involved in the review of the home. The financial procedures at the home are adequate ensuring the home is financially viable that safeguard the interests of service users. The systems in place for managing service users monies are satisfactory ensuring service users financial interests are protected. The arrangements for staff supervision are adequate ensuring staff are appropriately supervised. EVIDENCE: The manager stated she provided leadership and a clear sense of direction to staff. She remarked she led by example. The deputy manager commented the management style is open and supportive. The home had a policy on Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 21 equal opportunities and the manager stated she had regular senior management meetings to consult with the staff. The inspector noted meetings were held on the 26/10/05 and 9/11/05 and staff stated it was a good home to work and had a good atmosphere. One service user stated staff are very good, every one of them. The home had a policy on quality assurance dated 2002. The manager stated the home used a quality survey of resident’s questionaire to obtain feedback on the home and results are discussed with service users. The inspector noted the home had an Oakleigh feedback form that was in the foyer for information. Service users, staff, relatives and visitors were told about the Commission planned inspection and information was widely available throughout the home. The inspector noted the home met the requirements identified in the previous inspection report. The home had a business plan due for review in April 2006 and employers liability insurance due to expire in March 2006. The business plan covered areas of business overview, market and services, contracts, staffing plan and financial plan. The home had a policy on business management dated 2002 that covered financial procedures and service users’ money. The inspector noted the home employed a home administrator that had responsibility for service users’ money. The home had a system for managing petty cash and service users personal monies and all transactions were recorded. Monies were kept in named cash tins that were kept in a safe in the administrator’s office and all records were individualised, dated and signed. The home had a policy on staff supervision dated 2002. The manager stated she supervised the deputy, chef/manager, senior care officers and home’s administrator and senior care officers supervised carers and housekeeping staff. The inspector sampled supervision records and noted the home had a supervision review form that was dated and signed by the supervisor and supervisee. One supervision record was dated 4/11/05 and supervision covered the areas of care, philosophy of the home and career development. During a meeting a staff named her supervisor and remarked she had supervision every six weeks. Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 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 X 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 3 3 3 X X Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 23 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 NMS-OP 9 Regulation 12(1)(a) (b) Requirement The registered person must ensure staffs that administer medications are regularly assessed to ensure their competence to give medications and records of assessments are updated and available at the home for information. Timescale for action 20/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oakleigh DS0000028523.V255446.R01.S.doc Version 5.0 Page 25 - 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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