Inspection on 11/09/06 for Oakleigh

This inspection was carried out on 11th September 2006.

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 11/11/05

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 Unannounced Inspection 11th September 2006 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.V310302.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. Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 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 sharon.blackwell@anchor.org 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.V310302.R01.S.doc Version 5.2 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 registered with the CSCI (commission for social care inspection) to provide accommodation and care to fifty older people who have dementia, physical disability, learning disability or sensory impairment. The property is located in a residential area in Godstone, Surrey and close to local shops, pubs, parks and other public amenities. Accommodation is on three floors which is divided into five self contained units comprising of a lounge, dining room, kitchen, bathroom, shower room, toilets and bedrooms have en-suite facilities. The home has a lift to ensure the accommodation is accessible to service users. The home has a nice garden which is well maintained, accessible and secure. Private parking is available. The fees charged by the home range from £448 - £681 per week. The registered manager is Susan Eades. Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a site visit as part of the homes key inspection by the CSCI (commission for social care inspection) and carried out by one inspector over a period of six hours. The site visit commenced at 11:00 hours and finished at 17:00 hours. A partial tour of the premises took place, staff and service users were spoken to, and documents and care records were examined. The inspector noted some service users have memory impairment and judgements were made about them based on their mood, behaviour and information given by staff. CSCI leaflets and brochures were left at the home for information. The inspector would like to thank the deputy manager, staff, service users, and relatives for their contribution to the inspection. What the service does well: What has improved since the last inspection? Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 Page 6 The home has met the requirements made at the last inspection by the CSCI (commission for social care inspection) which has resulted in improvements in staffing levels and a strengthening of communication with the CSCI to safeguard the interest of service users. Care plans have improved and the home has applied for a variation to ensure it is operating within the categories of registration to safeguard the welfare of service users. 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. Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 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.V310302.R01.S.doc Version 5.2 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): 1,3&6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose is good ensuring prospective service users’ and their relatives have up to date information on which to make decisions about admission to the home. However, the service user guide needs improving to reflect the range of fees charged by the home. The arrangements for the assessment of needs must be strengthened to include a section on falls, personal safety and risks to ensure all aspects of service users needs are fully assessed before admission to the home. EVIDENCE: The home has a statement of purpose and service user guide which is written in plain English, nicely presented and available in the home for information. Following discussions with the manager a requirement has been made for information about the range of fees charged by the home to be included in the service user guide to ensure prospective service users have up to date information on which to make decisions about admission to the home. The deputy manager stated the home has an admissions policy and prospective service users are admitted to the home on the basis of an assessment of Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 Page 9 needs. A review of assessment records indicated the home had a preassessment form which covered personal care, social support and healthcare needs. Further evidence indicated the home had community care assessments by social services and the homes assessments were conducted by experienced staff including the manager, deputy manager and senior care officers to ensure service users needs are properly assessed and identified. Following discussions with the deputy manager a requirement has been made for the preassessment form to be updated to include a history of falls, personal safety and risk. The deputy manager stated the home does not offer intermediate care and this standard was not assessed. Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 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): 7,8,9&10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning at the home needs strengthening to reflect the changing needs of service users and promote health and personal care. The systems for accessing healthcare are good ensuring service users healthcare needs are assessed and met. The arrangements for privacy and dignity are good ensuring service users privacy is upheld. The management of medications at the home promote health. EVIDENCE: The deputy manager stated service users have individual care plans which are drawn up following an assessment of needs and the inspector noted the home had care plans which sets out in detail actions to be taken with regards to personal, social and health care needs. The deputy manager stated service users have named key workers and care plans are regularly reviewed and updated to reflect service users changing needs. The inspector sampled care plans which were in need of updating and action has been required in respect of this matter. During discussions a service user commented ‘‘we are very well looked after, yes we are’’ and a relative recorded ‘‘a very friendly and happy Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 Page 11 home, my mother is well looked after’’. The deputy manager stated service users have access to healthcare professionals to meet their needs and the inspector noted service users are registered with a local GP and the home have input from other professionals including chiropody, dental and optical services. The deputy manager remarked the home had a policy on medications and the inspector noted staff have training in medications to promote the health of service users. The home had a service level agreement with a local chemist and the inspector noted medication record sheets were dated and signed by staff. Further evidence indicated the home had adequate and safe storage of medications and the home kept a record to prevent mishandling of medications. During discussions a service user who self medicate remarked ‘‘I had a check from pharmacy, it all went very well’’. The deputy manager stated the home had a policy on privacy and dignity and the inspector noted the home had information on the GSCC (general social care council) code of conduct for care staff. Observations confirmed staff addressed service users by their preferred names and a care assistant knocking on doors before entering service users bedrooms to promote privacy. Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 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): 12,13,14&15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for activities need improving to satisfy the social, religious, cultural and recreational needs of service users. The systems for family contact are good ensuring service users maintain links with family and friends as they would wish. Opportunities for exercising choice are good ensuring service users are helped to exercise choice over their lives. Meals at the home are good and offer variety and choice. EVIDENCE: The deputy manager stated service users have planned activities and the inspector noted the home had an activity programme provided by volunteers from a local charity. Further evidence indicated activities were provided Monday to Friday, in the mornings and for one hour and included bingo, handicrafts, art group, ball games and song and dance. Following discussions the deputy manager stated activities in the home were under review and a requirement has been made for the home to employ a full-time activities coordinator to satisfy the social, cultural, religious and recreational needs of service users. In addition, any activities programme must be in a format which is understandable to service users with mental frailty. The home has no restrictions on visitors and the inspector noted relatives visited the home and used service users bedrooms for privacy. Further evidence indicated the home Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 Page 13 had contact with the local community and volunteers visited the home to promote community links. The home promoted choice and service users are able to bring personal possessions to the home. Further evidence indicated service users handle their own financial affairs for as long as they wish and the home had a list of advocates with telephone numbers to safeguard the welfare of service users. The catering assistant remarked the home had written menu plans and service users participated in planning the menu. A review of records indicated the menu offered variety, choice and met the dietary needs of service users. Observations confirmed meals were nicely presented and mealtime was relaxed and unhurried. During discussions a service user commented ‘‘food is absolutely first class’’. Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 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&18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints process is good with complaints information available to staff, service users and relatives. The arrangements for protection are good and safeguard the welfare of service users. EVIDENCE: The deputy manager stated the home had a complaints policy and the inspector noted information about complaints was available in the foyer and accessible to service users, relatives and professionals visiting the home. The deputy manager commented the home had a complaints folder which was sampled and no complaints were recorded since the last inspection by the CSCI (commission for social care inspection). During discussions a member of staff stated she was ‘‘aware of the complaints procedure’’ and it is recorded by a relative ‘‘the home is absolutely 100 ’’. The home had a policy on safeguarding adults and an up to date copy of the local authority (Surrey County Council) procedures on the protection of vulnerable adults. The inspector noted two allegations in respect of safeguarding adult matters were raised since the last inspection by the CSCI (Commission for Social Care Inspection) and investigated with appropriate management action taken by the home. During discussions a service user stated ‘‘the patience of staff is wonderful, it really is’’. Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 Page 15 Oakleigh DS0000028523.V310302.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 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. This judgement has been made using available evidence including a visit to this service. The arrangements for the premises are good ensuring service users live in a comfortable environment. The systems for hygiene are adequate ensuring the home is clean and hygienic for service users. EVIDENCE: The premises is comfortable and well maintained and the garden is tidy, attractive and accessible to service users. The inspector noted the home operated restricted access to the front entrance to promote the safety of service users and observations confirmed the home had a good standard of décor with adequate furniture and fittings. On the day of the inspection the home was clean and free from mal odour and the deputy manager stated the home had policies and procedures for the control of infection. Observations confirmed the home had laundry rooms with sluicing facility and staff practiced infection control measures by using gloves, aprons and washing their hands regularly to prevent the spread of infection in the home. Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 Page 17 Oakleigh DS0000028523.V310302.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 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 excellent. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are good ensuring there are sufficient numbers of staff to meet the needs of service users. NVQ (national vocational qualification) training for staff is excellent ensuring service users are in safe hands at all times. The systems for recruitment of staff are excellent protecting service users from harm or abuse. Induction training is good ensuring staff are trained and competent to do their jobs. EVIDENCE: The deputy manager stated the home had a staff rota and adequate staffing levels which were regularly reviewed to reflect the changing needs of service users. The inspector sampled the staff rota and noted the home employed a manager, deputy manager, senior care officers, care assistants, a head chef, catering assistants, housekeepers, an administrator and a handyman. Observations confirmed the home was appropriately staffed on the day of the inspection and a relative recorded ‘‘the level of care is very good’’. During discussions a care assistant commented ‘‘there is enough staff to do the job’’. The home is committed to staff training and development and fifty eight percent (58 ) of staff working at the home have the NVQ (national vocational qualification) qualification to ensure service users are in safe hands at all times. The deputy manager stated the home had a policy on recruitment of Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 Page 19 staff and the inspector sampled staff recruitment files which had completed application forms, references, statement of terms and conditions, health questionaire, CRB (Criminal Record Bureau) disclosure information and a recent photograph of the employee. The inspector noted recruitment files were well presented, maintained in good order and stored in a locked cabinet to promote confidentiality of information. Staff working at the home have induction and foundation training and the inspector sampled the induction workbook of employees which reflected the principles of care, safe working practices, the organisation and role of the employee. During discussions a member of staff stated ‘‘the training is fantastic, I have done POVA (Protection of Vulnerable Adults) and the training was marvellous’’. Oakleigh DS0000028523.V310302.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 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 good. This judgement has been made using available evidence including a visit to this service. The arrangements for the day to day management of the home are good ensuring service users live in a home which is run and managed by a person fit to be in charge of the home. The systems for quality assurance are excellent ensuring the home is run in the best interests of service users. Policies and procedures for managing service users’ money are good ensuring the financial interests of service users are safeguarded. The arrangements for safe working practices are good and promote and safeguard the welfare of staff and service users. EVIDENCE: The home has a registered manager who has the RMA (registered manager award) qualification and provides management stability, leadership and direction to the staff team. During discussions a member of staff stated ‘‘we have an extremely good manager who has the interests of service users and Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 Page 21 workers at heart’’ and it is recorded by a relative ‘‘the home is very well run, if I ever need to be in care I would be happy to live at Oakleigh’’. The home has a policy on quality assurance and a survey of service users and relatives was undertaken by an external consultancy to obtain feedback about the home. The inspector noted a report on the results of the survey was available in the home for information. During discussions a service user stated ‘‘we found heaven and I feel very safe’’. The home has a policy on service users money which has been revised and updated to safeguard the financial interest of service users and the home provided secure facilities for the safe-keeping of money and valuables. The homes administrator had responsibility for the management of service users monies and details of transactions were kept electronically for information and monitoring. The home had a policy on health and safety and staff had training in health and safety, food hygiene, first aid, manual handling and other relevant and appropriate training. The inspector noted the home had a policy on COSHH (Control of Substances Hazardous to Health) and a review of records indicated the home had a gas safety certificate, and records in respect of water temperatures and electrical equipment to promote safety. The kitchen appeared clean and hygienic and fridge and freezer temperatures were within normal limits to promote good food safety. Oakleigh DS0000028523.V310302.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 2 X X X N/A 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 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 OP1 Regulation 5(1)(b) Requirement Timescale for action 01/10/06 2. OP3 14(1)(d) 3. OP7 14(2) 4. OP12 16(2)(m) (n) The registered person must ensure the service user guide includes information about fees charged by the home to enable prospective service users to make an informed decision about admission to the home. The registered person must 01/10/06 ensure the assessment process includes an assessment of falls, personal safety and risks to ensure prospective service users needs are fully assessed before admission to the home. The registered person must 01/11/06 ensure care plans are regularly reviewed and updated, at least monthly, to reflect the changing needs of service users to promote health and personal care. The registered person must 01/12/06 ensure a dedicated activities coordinator is employed by the home to satisfy the social, religious, cultural and recreational needs of service users. In addition, information about activities need to be in a DS0000028523.V310302.R01.S.doc Version 5.2 Oakleigh Page 24 format which is understandable to service users with memory impairment to promote communication and choice in activities. 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 *RCN Good Practice Recommendations No recommendations were made at this inspection. Oakleigh DS0000028523.V310302.R01.S.doc Version 5.2 Page 25 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.V310302.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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