Inspection on 10/07/06 for Oakleigh Retirement Home

This inspection was carried out on 10th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Oakleigh Retirement Home 01/07/09

Oakleigh Retirement Home 09/07/08

Oakleigh Retirement Home 11/07/07

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

CARE HOMES FOR OLDER PEOPLE Oakleigh Oakleigh Road Clayton Bradford BD14 6NP Lead Inspector Ashley Fawthrop Key Unannounced Inspection 10th July 2006 10:00a 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 DS0000066814.V302717.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 DS0000066814.V302717.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakleigh Address Oakleigh Road Clayton Bradford BD14 6NP 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) 01274 880330 01274 817825 Crabtree Care Homes Sharon Vassell Care Home 31 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (31), of places Physical disability (1), Physical disability over 65 years of age (4) Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 Brief Description of the Service: Oakleigh is registered to provide personal care for up to 31 older people, a small number of whom may be diagnosed with a physical disability or dementia. The home is situated in the Clayton area of Bradford, approximately 3 miles from the city centre. There are bus routes to Halifax and Bradford. There are good communal facilities in Clayton village including banks, shops, post office, hairdressers and pubs. Service users and staff prefer the term residents, therefore this term has been used throughout this report. The fees range from £344.75 and £37.00. Extra charges are levied for hairdressing and chiropody. Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out without prior notification and was conducted by one inspector over the course of one day. The inspection started at 9.30am and finished at 4.00pm. Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents and incidents, the action plan submitted following the previous inspection, and reports from other agencies, i.e., the Fire Officer. This information was used to plan the inspection visit. The inspector case tracked three service users. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Pre admission information was available to service users and pre admission assessments were done. Care plans are available for all service users, however, some information required to be updated and dated so they reflect the needs of the individual. The environment is comfortable and well maintained and decorated to a good standard. The staff turnover is low ensuring a consistent approach to the day-to-day care of the residents. The training for staff is much improved since the last inspection and supervision has commenced but must be carried through for all staff if service users are to benefit from staff development and training. What the service does well: A manager qualified to do so manages the service consistently. The records are reasonably up to date and staff are well trained. Activities are aimed at the abilities of the residents. The activities are diverse to meet the needs of specific groups these include nail painting for female residents. Different religious activities and gardening for a small group. There is evidence that the care given to very frail service users is good, communications between service users representatives and the home is good. Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Oakleigh DS0000066814.V302717.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 DS0000066814.V302717.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, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The home provides information to residents prior to admission in sufficient detail for them to make a judgement on whether the home can meet their needs. The home also recognises the importance of gathering information prior to admission to ensure they can meet the needs of the individual. EVIDENCE: The statement of purpose is available to prospective residents and their representatives. The document includes the philosophy of care and daily activities. There is also information on the environment and policies regarding personal possessions, finances and complaints. Other information includes the lay out of the home and numbers of single and twin rooms, staff training and how the needs of people from different backgrounds, cultures and disabilities will be met. Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 Page 9 The statement of purpose is made available to prospective residents and their families enabling them to assess whether the home can meet their needs or not. A copy is also available in each bedroom enabling residents to have access to important information such as the complaints procedure. This is good practice. Pre admission assessments are undertaken for all service users. This allows staff to make a judgement on the needs of the individual in their present environment and gives them an opportunity to ensure that the home can meet the needs of the individual prior to admission. This is good practice. The manager informed me that wherever possible service users are offered a visit to the home prior to admission, however, there is no recording of such visits. This is a missed opportunity for staff to assess the level of care required before admission. This home does not provide intermediate care. Oakleigh DS0000066814.V302717.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. On the whole care planning is good and the needs of frail service users are being met. However, recording must be improved and instructions to staff must be clear. The present practice of medication administration is unsafe and must cease. EVIDENCE: Three of the residents were case tracked as part of the inspection and information on the whole was consistent in each plan and related to the needs of the individual service user. Assessments on daily living were available as were risk assessments relating to mobility, mental and physical needs. On those care plans I inspected information relating to life histories and pen pictures was available to staff giving them a picture of an individuals past life experiences had been and what makes them the individual they were today. Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 Page 11 On two care plans the information was good yet on one other it was more a past medical and did not relate to the person as a whole but highlighted medical problems. In the text of a pen picture it was irrelevant as it had been recorded on the assessment. There was evidence of good care being provided to individuals who were very frail and needed high levels of care. The care plan reflected the needs of the individual and there was evidence of other health care professional being involved where needed. Visitors said they were very happy with the care given by the home. The staff are consistent and do not leave so they know how to deliver the care. Communication is good and staff inform relatives if the health and well being of their relatives change. However, some relatives did say that they did not know what was written in the care plan and had not been involved in its development or reviews. This is not good practice. Staff need to involve the resident and their representatives in the care planning process so that it reflects the true needs of the service users. On reading care plans some of the recording was not accurate, as dates had been missed. In other areas information to staff was contradictory which would be confusing and could lead to staff taking two different approaches to one problem one of which would be wrong. The policies and procedures relating to the recording and administration of medications is safe and are available to staff. However, on observing the practice of administering medication I observed one member of staff giving the medication to another member of staff to administer. This practice could result in the service users receiving the wrong medication. Secondary administration is poor practice and must not continue. Oakleigh DS0000066814.V302717.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The home is aiming the activities towards the abilities of the residents. Diversity is being addressed in activities and individual needs are being met. Staff must look at the way they address the needs of individuals at meal times to ensure every service users has the opportunity to eat their meal when it is hot. EVIDENCE: There are a high number of service users with dementia related illnesses. Activities are undertaken on a one to one service and in groups. Diversity is addressed in some activities the residents can have their nails painted or differing religious services are available. These activities address the wishes of different groups. This is good practice. Other activities include walks, singing, exercise to music and for a small number of service users gardening. Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 Page 13 There is an activity coordinator to visit the home on a monthly basis to coordinate activities. The meal on the day of inspection was steak pie mashed potatoes and vegetables, followed by a warm sweet. Residents have a choice of where they eat, there is a dining room available, some prefer to eat at their chairs and portable tables are available and there are a number who eat in their rooms. There are a number of service users who need their food liquidised this was given through a feeding cup. I observed one staff assisting more than one service user this was not good practice as the meal would be going cold. Staff were also observed to be carrying four plated meals on top of each other on a tray. This practice looked hazardous and a risk assessment of the practice must be undertaken. Oakleigh DS0000066814.V302717.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The residents are not protected by the complaints procedure, as there is no documentation that changes take place as a result of a complaint. Service users are protected by the policies and training relating to adult protection. EVIDENCE: There is a copy of the complaints procedure in each service users room. The procedure is easy to follow and informs the individual how to complain and who to complain to. This is good practice. On inspecting the records of complaints the last complaint was in 2005. The Commission has not received any complaints since this date. Complaints made to the home are documented in a hard backed book with the date of the complaint the complainant and what the complaint was about. This is inadequate. Complaint documentation must include what action has been taken by the home in relation to the complaint and the outcome. The complainant must be informed in writing of the outcome and any changes within the home that have been introduced to prevent the situation arising in the future. Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 Page 15 On talking to residents individuals said that they could complain if they were unhappy and knew the senior members of staff who they could complain to. There are policies and relating to the protection of vulnerable adults and whistle blowing. Eight members of staff have undertaken training in adult protection since 2005. This is good practice. Oakleigh DS0000066814.V302717.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, 21, 23 and 26. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The environment is safe in a good state of repair and comfortable for service users. EVIDENCE: The home has a safe and well-maintained environment there are aids and equipment to meet the needs of the residents. The rooms meet the National Minimum Standards and a number have en-suite facilities. On touring the building there were sufficient numbers of bathrooms and toilets within easy reach of communal areas. Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 Page 17 There is evidence that residents have the opportunity to personalise their rooms with furniture and personal possessions ensuring individuality and ownership. This is good practice. The residents were generally happy with their rooms and said they can enjoy their own privacy if they wish. The water was sufficient hot water, however, one resident said that the water was not hot in his room this is being investigated by the manager. The home is generally clean and tidy with no odours on the day of the inspection. There are cleaning materials and equipment is available. Oakleigh DS0000066814.V302717.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. To fully ensure the protection of the residents the home must ensure all information is gathered when recruiting staff. EVIDENCE: Comments from relatives of residents included that they have always found the staff to be diligent and attentive to the needs of the residents at all times. Evidence to support this in the staff training that includes NVQ training at levels 2,3 and 4. Other training includes protection of vulnerable adults, food hygiene, fire training, moving and handling, infection control, and first aid. There is a low turn over of staff this allows the home to deliver consistent care by staff who know the needs of the service users. The recruitment and selection procedures on the whole are robust, however, there was one employee who only had one written reference and a second the Criminal Records check was not on file. All staff had undertaken an induction period and had a training and development plan. Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 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 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, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. A competent manager manages the home appropriately and the residents and staff are kept free from harm by the health and safety policies and procedures. All staff must be regularly supervised. EVIDENCE: The manager of the home has a nursing qualification and is trained to NVQ level 4. She has managed the home for some time and has a good knowledge of the management systems of the home and the needs of the residents. Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 Page 20 Her management style is open and transparent and the views of service users and their representatives are taken into account in developing the service. This is done through informal meetings and reviews however, this system must be formalised and a development plan for the home developed and reviewed at regular intervals. The homes policies and procedures are reviewed effectively in line with current practice. The records are generally of a good standard, however, some work continues to be required on care plans to ensure they are appropriately dated. The records relating to the residents fiancés are up to date easy to follow and transparent. This is good practice. Two staff have received supervision by the manager but to the date of the only one had been recorded. The manager must prioritise the supervision of staff if service users are to benefit from the staff development. There is a clear health and safety policy. There are records of checks for essential supplies such as gas electric and water. However, the fire system must be tested regularly and fire drills must be undertaken at least twice per year. Maintenance to hoists and bath aids are up to date. Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X 3 X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 (1) Requirement Service users and their representatives should be consulted as to the content of the plan in respect of their health and welfare. The information documented in the care plan must be dated and instructions to staff should not be contradictory causing confusion. Staff must not continue with the practice of secondary medication administration as this may lead to the service users receiving the wrong medication. When staff must assist service users to eat there must be sufficient numbers of staff to do this on a one to one basis. All service users should receive their food while it is warm. Complaints documentation must include the investigation and outcomes of the investigation. The complainant must be informed in writing of any action to be taken in relation to the complaint Timescale for action 30/11/06 2 OP8 12 30/11/06 3 OP9 13 30/11/06 4 OP15 16(2)(i) 31/10/06 5 OP16 22(3) 31/10/06 Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 Page 23 6 7 OP25 OP29 23 19 8 9 OP36 OP38 18(1) 23 The registered provider must ensure bedroom 16 & 25 are appropriately heated. The registered manager must not employ a person to work at the care home unless all the relevant documentation is obtained. (Previous timescale not met 30/11/05) All staff must be formally supervised at regular intervals with documented outcomes. The registered person must ensure that the fire system is appropriately checked and drills are held at least two times per year. 30/11/06 31/10/06 30/11/06 31/10/06 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. 3. 4. Refer to Standard OP2 OP7 OP12 OP15 Good Practice Recommendations The registered manager should issue statements of terms and conditions to residents when they move into the home. The registered manager should continue to develop strategies for involving residents in the care planning process. The registered manager should continue to develop activities for service users. The registered manager should make sure any changes to the menu are recorded. Oakleigh DS0000066814.V302717.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 DS0000066814.V302717.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. 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