Inspection on 21/04/05 for Oakleigh

This inspection was carried out on 21st April 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 11/11/05

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 Mr D Ramdas Unannounced 21st April 2005 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 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 H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Oakleigh Address Evelyn Gardens Godstone Surrey RH9 8BD 01865 854000 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Anchor Trust Mrs Susan Eades Care Home 50 Category(ies) of DE(E) - Dementia - over 65 (15) registration, with number of places LD(E) - Learning Disability - over 65 (1) OP - Old Age (24) PD - Physical Disability (5) PD(E) - Physical Disability - over 65 (5) Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 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. Date of last inspection 13th October 2004 Brief Description of the Service: The Care Home was designed and built by to high standards of architecture. The provider is the Anchor Trust. The care home is registered to provide personal care and it can accommodate fifty service users within the category of dementia, learning disability, old age and physical disability. The accommodation is set on three floors and divided into five units. Each unit is self contained and has a communal loumnge, dining room, a kitchen, bathroom, showeroom, toilet and washing facilities. Bedrooms are single, spacious and with en-suite facilities. The care home is located near the village of Godstone and close to public amenities. The care home is managed by an experienced Manager who has the appropriate knowledge and skills to lead the service. Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out by two inspectors over an eight hour period. The premises were inspected as well as documents and records. A number of staff, service users and relatives were spoken to. Comment cards were handed out to service users, relatives and the Manager. What the service does well: What has improved since the last inspection? Although the building is only three years old management have commenced a rolling programme of redecoration and refurbishment to ensure a good standard of environment is maintained. A lounge carpet had been replaced in one of the living units. A positive development was the recent success in recruiting a receptionist for the home who was due to take up post in May to relieve senior care staff of these duties. Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 6 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 H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 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 standard(s) 1, 4 Service users and prospective service users were provided with sufficient information enabling them to make a decision about admission to the home. Although the home’s capacity to meet assessed needs of service users was mostly demonstrated further improvement in the environment was necessary to ensure needs of people with visual impairment are met. EVIDENCE: The Statement of Purpose was detailed, clearly written and provided a range of information. It detailed the aims and objectives, philosophy of care, services and facilities, staffing and management arrangements On the day of the inspection, and at the suggestion of the inspectors the Statement of Purpose was updated to show the address of the Commission for Social Care, Local Office in Eashing, Surrey. At the time of the inspection a service user who was partially sighted was accommodated for respite care. The service is not registered to accommodate individuals with sensory impairment and a requirement has been made in this area. Though this individual expressed a high level of satisfaction with the care received he did acknowledge difficulties in finding his room and his way round his room. There had been no assessment of this individual’s needs by the home specific to his sensory impairment and this was not addressed in his care Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 9 plan. Observations confirmed small but significant improvements to the environment, for example aids, improved lighting and brightly coloured labelling, would have afforded a more enabling environment for this individual. Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 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 standard(s) 7, 8 and 10 Service users health, personal and social care needs are set out in individual care plans. The standard of care planning and record keeping was inconsistent across the home. Care plans and risk assessment were in need of further development. Health care needs were met and health care services accessed as necessary. Arrangements for personal and health care respected service users privacy and dignity. EVIDENCE: Service users expressed a high level of satisfaction with standards of care. One individual stated “we are cared for very well. I have a lovely comfortable room and staff respect my privacy and always knock on my door”. Service users consulted considered their needs to be well met. Each service user had a care plan setting out the action to be taken by care staff to ensure health, personal and social care needs are met. Observations confirmed some care plans did not fully address all aspects of need. Record keeping practices in relation to care plans varied across the home. Whilst some were to a good standard, others were not dated and signed. It was not fully demonstrated that service users were involved in drawing up their care plans. Inconsistency was observed on the frequency of reviewing care plans, some Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 11 staff did not record monthly reviews. Risk assessments also required improvement. This had been identified by management prior to the inspection, although interim attention was drawn to areas requiring immediate action. These included a high risk identified for a service user involving an item of equipment with no care plan for the safe management of that risk. Also failure to carry out a risk assessment for a respite user responsible for administration of medication to another service user, admitted for respite care. Discussions included the need to ensure pressure sore prevention risk assessment systems are in place. Also for pressure relieving equipment to be documented on care plans. It is acknowledged that the home receives good support from the district nursing team who provide tissue viability input as required. Infection control procedures were of a good standard. Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 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 standard(s) 12, 13 and14 The routines of daily living and activities were sufficiently flexible to enable service users to exercise choice and control in their daily lives within individual capabilities. The social activities programme offered variety and effort was made to meet individual’s interests though not always identified through the care planning process. Service users maintained contact with their families and friends and community links were well established. EVIDENCE: Information about local activities and events of interest to service uses was prominently displayed by the reception. The home’s activity programme for the month was also displayed and art -work produced by service users who were members of the home’s Acorn Art Group was exhibited in the reception area. The activity programme was varied and incorporated involvement of volunteers. On the day of the inspection a group of service users were observed enjoying an activity organised by two volunteers. Service users said they very much enjoyed the gentle exercises to music provided three times a week by a trained volunteer. Throughout the home were photographs of various social events, parties and holidays organised by the home and enjoyed by service users. The home had a wheelchair accessible mini – bus which enabled service users to access community facilities. Service users enjoyed going to local pubs and garden centres. Although the mini-bus was well maintained and currently Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 13 reliable it was ageing and individual service users expressed concern for the future in the event that it broke down and was not replaced. Individual service users described the mini bus as a “life-line” which enabled them to be part of the community. A service user had been unsuccessful in generating local interest in fundraising for a new mini-bus. Discussions with the Manager at the time of the inspection confirmed recognition of the need for a long - term plan for provision of transport to ensure needs continue to be met. Observations confirmed that although service users interests were not always recorded that staff had good knowledge of the same and made an effort to provide appropriate stimulation based on this information. Visitors in the home were made welcome by staff at the time of the inspection and had opportunity to talk with service users in private if they wished. Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 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 standard(s) EVIDENCE: This area was not assessed during the inspection. Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 15 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 standard(s) 19,20,21,22,23,24,25,26. The standard of the environment within this home is very good providing service users with an attractive, comfortable and safe place in which to receive care and support. There is a need to ensure assessment of the premises to ensure suitability for meeting the needs of service users with sensory impairment. EVIDENCE: The building was well maintained. It was well decorated and the carpets were clean and free from mal odour. The home was spacious with good quality lighting, heating and ventilation. A portable air conditioning unit was located on each floor. One service user, remarked, she enjoyed living at Oakleigh. Bedrooms were individualised with service users encouraged to keep personal possessions. Family photographs were on display. One service user who was a keen football fan had an Arsenal Football Club calendar in his bedroom. The gardens were well kept, private and secure. It was also easily accessible for Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 16 service users who were in wheelchairs. One relative stated, the handyman had done a good job with the gardens. Comments on observations that concluded the need for improvement to the environment to meet the needs of service users who have a sensory impairment are detailed on page 9 of this report. Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Service users needs were not fully met by the deployment and numbers of staff on duty at all times. However, staff morale was high resulting in an enthusiastic workforce that worked positively with service users to improve their whole quality of life. EVIDENCE: The manager reported good retention of staff despite the upheaval during the period when the home had been rebuilt and the home had operated on another site. There was ongoing recruitment to the 100 hours care staffing vacancies. Though personnel records were not inspected advice was sought on a query about vetting documentation missing on some staff files. At the time of the inspection service users with high dependency needs were noted to be without staff observation for a lengthy period of time in the afternoon. A visitor commented that staff appeared to be under pressure at times to meet the demands of care. It was stated that staffing levels had not kept pace with the increasing dependency of service users, that it had not been raised since the home opened. The Manager confirmed she had recently revised the deployment of staff across the waking day shifts, in consultation with staff to provide more staff on duty during peak activity times. The atmosphere of the home was genuinely warm and welcoming. Harmonious relationships existed between management and staff. There was evidence of positive team working and a supportive environment for service users and staff. Service users spoke well of all the staff team and one service user Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 18 summed up the collective views received from those who gave feedback in the following question addressed to an inspector “ I hope you are as happy with our care and the home as we are?” Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 37 and 38 The management of the home provided effective leadership, guidance and direction to staff to ensure service users received consistent quality care. Records were maintained mostly in accordance with requirements though attention was required to care plans and risk assessments. The systems that are in place at the home promote safe working practice but need some improvement for the protection of service users. EVIDENCE: The home’s management team was observed to be cohesive and effective. The Manager demonstrated continuous training that built on her qualifications and experience, ensuring competencies for managing the home. The Manager had achieved the Registered Managers In Care Award NVQ Level 4 (RMA). The Deputy Manager was part way through studying for the RMA, held an NVQ Assessor Certificate and had recently attained an NVQ Internal Verifyer Certificate. The home’s management were highly committed to enabling staff to enhance their skills and knowledge through the home’s training programme. They were of the view that this was key to good quality care provision. The Manager informed the inspectors that 52 of staff had attained at least NVQ Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 20 Level 2 Certificate in Care. The inspection did not include examination of staff’s training records on this occasion. The premises was secure. There is an intercom system in place at the entrance and in the foyer there is always a member of staff at the front desk. Infection control procedures are in place. On the day of the inspection there were two cleaners on duty. The home has a Moving and Handling trainer to show the staff how to practice safely. There are up to date service records on equipment used in the home. The minibus also has current service records. Information is readily available on Health and Safety legislation. On the day of the inspection, the inspectors found the hot water supply in the shower room exceeded 43 degrees centigrade. This was put right during the inspection. The Manager was requested to ensure notifications to the Commission ensured these were within the full scope of guidance from the Commission a copy of which was left at the time of the inspection. This includes notification of MRSA and pressure sores classified grade 2 and over. Reports of statutory monthly visits conducted on behalf of the Responsible Individual in compliance with Regulation 26 of the Care Homes Regulations 2001 must be sent to the Commission for auditing. Please refer to the comments on Page 9 of this report in respect of the home operating outside the conditions of registration in respect of the category of sensory impairment. Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x x x x x 2 3 Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 22 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. 1. Standard OP 4, 22 Regulation Requirement Timescale for action 01/06/05 2. OP 7, 12, 37 3. OP 8 4. OP 27.1 27.3 14(1)(a)(c The registered person must not (d) provide accommodation to a 23(1)(n) service user within a category for which they are not registered. An application for a variation to the conditions of registration must be submitted to CSCI in respect of a service user who falls within the category of sensory impairment. 15(1)17(3 For the registered person to 01/06/05 ensure care plans address all risks and needs, including social care needs. They must be written in consultation with service users, signed and dated by staff and reviewed at least monthly. 13(4) For arrangements for prevention 01/06/05 of pressure sores to be proactive and risk assessments carried out by a suitably trained person. Care plans for service users at risk of developing pressure sores must include all appropriate interventions and detail requirements for pressure relieving equipment. 18(1)(a) The registered person must 01.08.05 conduct a review of staffing levels on the ground floor to Version 1.30 H58_28523_Oakleigh_v220539_210405_stage4.doc Oakleigh Page 23 5. OP 37 26(5)(a) 6. OP 38.7 37 (b) 7. 0P 38.1, 38.2,38.6 13(4)(c) ensure that at all times suitably experienced staff are working at the care home in such numbers as appropriate for the health and welfare of service users. Once completed a copy of the outcome of the review must be sent to the Commission. The registered person must 01.07.05 ensure a copy of the monthly Regulation 26 report is sent to the Commission. The registered person shall give 01.05.05 notice without delay, to the Commission, of the occurrence of any infectious disease. The registered person shall seek 01.07.05 advice from the Fire Safety Officer as to door guards being fitted to bedroom doors in order to ensure that unnecessary fire risks are eliminated. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard Good Practice Recommendations Oakleigh H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 Page 24 Commission for Social Care Inspection 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 H58_28523_Oakleigh_v220539_210405_stage4.doc Version 1.30 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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