Inspection on 15/07/07 for Oakleigh

This inspection was carried out on 15th July 2007.

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 21/05/09

Oakleigh 06/06/08

Oakleigh 11/08/06

Oakleigh 25/10/05

Oakleigh 11/01/05

Oakleigh 26/11/04

Oakleigh 20/07/04

Oakleigh 27/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Oakleigh 22 Great North Road Alconbury Weston, Huntingdon Cambridgeshire PE28 4JR Lead Inspector Dragan Cvejic Key Unannounced Inspection 15th July 2007 12:30 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 Oakleigh DS0000015107.V339610.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 DS0000015107.V339610.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakleigh Address 22 Great North Road Alconbury Weston, Huntingdon Cambridgeshire PE28 4JR 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) 01480 890248 01480 896308 Mr Styllianakis Styllis Celia Ann Harris Care Home 27 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (27) of places Oakleigh DS0000015107.V339610.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th August 2006 Brief Description of the Service: Oakleigh provides accommodation, care, and support for up to 27 older people, 2 of who have a degree of dementia. The home is in the small village of Alconbury Weston, which has a shop, public house and church, and is within easy reach of Huntingdon and Peterborough. The building was originally a private bungalow but it has been extended a number of times and now offers accommodation in 24 rooms on the ground floor, and one room on the first floor which is accessed by a stairs or a stair lift. All 25 rooms have en-suite facilities; the two double rooms are currently used as superior singles. The building surrounds an attractive central courtyard; residents have a choice of communal accommodation, including 3 lounges and a dining room. The gardens surrounding the house are attractive, well maintained and frequently used by the residents and their families. The home is staffed 24 hours a day, with 2 staff on duty overnight. Oakleigh DS0000015107.V339610.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. Two inspectors visited the home and spoke to residents and staff. The home carried out a self-assessment using AQAA tool and 7 questionnaires were returned directly to regulation authority. The inspectors checked 4 residents’ files and 3 staff files. A tour of the building provided direct information about the environment used for this report. Four residents talked about their experience of life in the home. A relatively new methodology named SOFI: Short Observation of Framework for Inspection, was used to inform the level of care for some residents who could not provide verbal comments. What the service does well: What has improved since the last inspection? A new induction programme was introduced for staff that covered specific conditions of residents and helped new staff respond to residents needs right from the commencement of their work. Residents requested new sit-on weight scales and the home acquired them. The lunchtime was also changed as residents wanted and voted for on their meeting. A new hoist and appropriate training for using it started to provide the effect of making residents safer when they were moved by the use of this facility. Care plans and recording was improved. The home identify a higher risk of falls for a resident and acquired a special warning mat that alerted staff when the resident moved and allowed them to prevent falls. The device was still being tested during the site visit and the effects were observed as a part of the inspection. Oakleigh DS0000015107.V339610.R01.S.doc Version 5.2 Page 6 The manager reviewed the job description for deputy manager and updated it with accurate description of duties, responsibilities and rights. 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. The summary of this inspection report can be made available in other formats on request. Oakleigh DS0000015107.V339610.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 DS0000015107.V339610.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The initial assessment and admission procedure ensured that service users could make an informed decision and that the home would accept them when sure that their fully assessed needs could be met. EVIDENCE: Four residents’ files were checked and all contained documentation from initial assessments. It included information from social services, family members and residents’ comments. This was particularly important as seen in two files where allergies were recorded and helped create care plans where this risk was minimised. The admission process included checking how the new residents would fit into the existing group. This part of the assessment ensured that residents’ needs would be fully met, if they were admitted. Oakleigh DS0000015107.V339610.R01.S.doc Version 5.2 Page 9 Five residents were supported financially by the council of health trusts, while 17 were privately funding their places. The Home reviewed private contracts. Oakleigh DS0000015107.V339610.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. 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. The home was constantly improving health and personal care standards and was significantly moving towards exceeding the outcomes for these standards, in particular with the respect for privacy and dignity. EVIDENCE: The improved care plans were clearer and better understood by staff and by residents that were involved in care planning. Although residents knew about care plans reviews, their signatures were only in the archived documents and not in working files. The home was involved with co-operative work with the Falls prevention team form Hinchinbrooke Hospital. They acquired a new device for detecting resident’s movements and were testing the device with a resident with a history and high risk of falls. This process was observed during the site visit and demonstrated its effectiveness. Oakleigh DS0000015107.V339610.R01.S.doc Version 5.2 Page 11 The home also involved a district nurses team for prevention of pressure sores and ensured a fast response that reduced the occurrences and improved healing. Good use of personally identified charts allowed effective monitoring of conditions affecting individual residents and responding to any change in a timely manner. A recent outbreak of diarrhoea and vomiting was well handled, contained and eliminated within a short period of time with extra efforts from staff. Medication policy and procedures were in place and the checking of records, storage of medication and a short observation, demonstrated the appropriateness of the procedure. One of the main strengths of the home was the level of respect for residents’ privacy and dignity. All residents’ spoken to and 5 questionnaires praised the home and the staff for their dignified approach to residents. Residents’ meetings offered the opportunity for residents to influence and direct how daily life was organised. Residents asked for a change of lunchtime. They also wanted new sit-on scales for monitoring their weight. The home responded to these initiatives. Oakleigh DS0000015107.V339610.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. 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. Although residents were in control of their daily routine and the home provided different activities, both residents and staff identified activities as an area that could be improved. EVIDENCE: “My family regularly visit me and they are happy when they come”, stated a resident spoken to. Three lounges and several seating areas for visitors provided an opportunity for residents to spend time with their visitors in communal areas too, rather than solely in their rooms. Residents voted to change lunchtime hours at their meeting, to a time they preferred. The home provided various activities and recorded attendance ensuring that all residents get the opportunity to enjoy what they prefer. However, this area was identified by the home as one for further improvements. During the site visit the majority of residents attended a church service, arranged in the home. Oakleigh DS0000015107.V339610.R01.S.doc Version 5.2 Page 13 The home did not deal with residents’ money, but their families were helping when it was necessary with this aspect of their care. Residents were encouraged to bring in personal items and the records of these were kept. The checked file contained a record noting: a mirror and radio. The majority of comments received praised the food as being tasty, pleasant smelling and varied. The manager stated that the home promoted a healthy diet. One comment described the food as “having too much mashed potatoes and rice pudding.” The home introduced a food chart and recorded all food intake for residents whose weight needed monitoring. “Kitchen is spotless”, commented a family member in the questionnaire. Oakleigh DS0000015107.V339610.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. 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. Service users were protected by the home’s complaints procedure and other policies created to protect them. The manager ensured better protection by addressing all potential issues through appropriate recording and analysis of events. EVIDENCE: The home had a simple and clear complaints procedure. Three residents spoken to confirmed that they would complain if they had any concerns and would know how to raise the procedure. A member of staff spoken to also stated, on behalf of the whole staff team, that staff were confident that their concerns would be looked into. The procedure had a clear deadline in terms for each stage of the procedure. The staff were trained on protection and, to improve further protection, extra training on Whistle blowing was provided for all staff. All visitors including external professionals were checked before they were let into the home, to ensure the protection of residents. The new recruitment procedure included obtaining CRB, POVA and two references for all staff before an offer for employment was made. There were several staff members that had worked in the home for a number of years, for whom references were not obtained at the time they started work, many years Oakleigh DS0000015107.V339610.R01.S.doc Version 5.2 Page 15 ago. However, staff files of new workers contained all required vetting documents. Oakleigh DS0000015107.V339610.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): 19,20,21,22,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided a comfortable and well-maintained environment where service users needs could be met. EVIDENCE: A brief tour around the house included checking communal areas and 5 residents’ rooms. Sanitary facilities were also checked. All checked areas were clean, comfortable and nicely furnished. The records of servicing equipment demonstrated regular checks. Health and safety records contained up to date risk assessments and the COSHH assessments were up to date too. Communal areas were re-carpeted since the last inspection. A new hoist and new sit-on scales were obtained. Oakleigh DS0000015107.V339610.R01.S.doc Version 5.2 Page 17 The home had a plan for regular maintenance, repairs and replacements. The plan contained re-carpeting of residents’ rooms and a major improvement: the installation of a wet/shower room. Oakleigh DS0000015107.V339610.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): 27,28,29,30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home employed staff following a tightened recruitment procedure, introduced a new, expanded induction and ensured better protection of residents through monitoring and improving staffing standards. EVIDENCE: Staff files were improved. Three files were checked, two of the staff being here for a number of years, and one of the newer staff members. In addition, the deputy manager stated that she had got a new, revised contract and job description that outlined accurately her duties and responsibilities. The staff rota showed the shift pattern, which was designed according to the residents’ needs. Some comments received during the survey indicated that some residents wanted more staff on duty during the weekends. The manager stated that she was already looking into changing the shift pattern, as a general improvement of service and provisions. Three staff worked mornings, two during daytime and three on afternoon shifts, covering busy periods and disengaging staff during the quieter parts of the day. Qualified staff ratio exceeded standards by having 90 of staff NVQ qualified and promoting this training for all new staff. Oakleigh DS0000015107.V339610.R01.S.doc Version 5.2 Page 19 The new, improved recruitment procedure included all checks carried out prior to start of employment. The manager and her deputy were signatories for CRB checks and ensured that all staff had their CRB prior to starting work. Training was also significantly improved and covered not only mandatory subjects, but also topics related to residents’ conditions, such as continence care, skin care and dementia. Inductions were personalised and the duration was decided for each individual, with the main framework set for the first six weeks, but allowing an extension for as along as each individual needed. This aspect also exceeded standards. A resident commented: “They are excellent”, on his view of staffing. Oakleigh DS0000015107.V339610.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): 31,33,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were protected by safe working practices, regular reviews of potential effects on health and safety in the home and the skilled management of the home. EVIDENCE: The manager was qualified, experienced and had completed her Registered Manager’s Award training. The proprietor and the management carried out quality assurance surveys among residents and staff. They collected comments and information and provided feedback when the action plan was drawn up. The home valued Oakleigh DS0000015107.V339610.R01.S.doc Version 5.2 Page 21 comments from residents’ relatives and families and respected their comments. The home did not deal with residents’ money and encouraged residents to arrange financial support from families or the most appropriate supporters. The staff supervision programme was regular and covered aspects of practice and personal development needs. Health and safety and the welfare of residents had been ensured through safe working practices and policies and procedures. A new computer helped better management. The communication between management and staff was improved. Records of health and safety checks were inspected, including, fire safety records, and checking of the equipment. Infection control measures were in place. Accident/incident records were checked for case tracked service users. Based on the analysis of these records, the need for preventative action for falls was identified, planned and acted upon. The new induction programme was much better, individually tailored and flexible in terms of the completion timescale. Oakleigh DS0000015107.V339610.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 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Oakleigh DS0000015107.V339610.R01.S.doc Version 5.2 Page 23 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 should be signed in the working part showing residents’ involvement. Oakleigh DS0000015107.V339610.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Oakleigh DS0000015107.V339610.R01.S.doc Version 5.2 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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