Inspection on 11/07/07 for Oakleigh Retirement Home

This inspection was carried out on 11th 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 Retirement Home 01/07/09

Oakleigh Retirement Home 09/07/08

Oakleigh Retirement Home 10/07/06

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Oakleigh Retirement Home Oakleigh Road Clayton Bradford BD14 6NP Lead Inspector Ashley Fawthrop Key Unannounced Inspection 11th July 2007 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 Retirement Home DS0000066814.V339740.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 Retirement Home DS0000066814.V339740.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakleigh Retirement Home 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 Bel Air Care Limited Sharon Vassell Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Oakleigh Retirement Home DS0000066814.V339740.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th July 2006 Brief Description of the Service: Oakleigh is registered to provide personal care for up to 31 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. The fees range from £329.75 and £370.00. Extra charges are levied for hairdressing and chiropody. Oakleigh Retirement Home DS0000066814.V339740.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and done by one inspector within one day. 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. I 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 the people who live there and staff were considered. Pre admission information was available to people and pre admission assessments were done. Care plans are available for all people who live there. 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 people. What the service does well: What has improved since the last inspection? The information in the care plans has improved and there is evidence that people are involved in the planning of their care. Oakleigh Retirement Home DS0000066814.V339740.R01.S.doc Version 5.2 Page 6 Unsafe practices in administrating medications have stopped and the manager has looked ways of making sure that people who need assistance at mealtimes are helped. The complaints recording system has been improved and problems with the hot water system have been improved. All staff have checks undertaken by the Criminal Records Bureau this protects people from potential abusers. Improvements have been made to the records relating to health and safety and the fire system. 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 Retirement Home DS0000066814.V339740.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 Retirement Home DS0000066814.V339740.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): 1, 3, 4 and 6 People using the service experienced good quality outcomes. This judgement has been made using available evidence including a visit to this service. The home provides information to people and assessments undertaken before they move into the home. People also have the opportunity to visit and see the home and the services offered. EVIDENCE: The statement of purpose continues to be available to people before they move into the home. This is good practice because it gives people the information about the services provided so they can make an informed decision as to whether the home can meet their needs. Oakleigh Retirement Home DS0000066814.V339740.R01.S.doc Version 5.2 Page 9 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. Assessments continue to be done before people move into the home. This allows staff to make a judgement on the needs of the individual in their present environment and gives them an opportunity to make sure that the home can meet the needs of the individual prior to admission. This is good practice. People continue to be offered a visit to the home before they move in but as written in last years report there is no recording of such visits. This continues to be a missed opportunity for staff to assess the level of care required before admission. I recommended that these are added to the information written in the care plan before admission. This is good practice. This home does not provide intermediate care. Oakleigh Retirement Home DS0000066814.V339740.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 and 10 People using the service experience good quality outcomes. This judgement has been made using available evidence including a visit to this service. Care planning is good and the the health and personal needs of people are being met. The medications procedures were seen to be safe and people are treat with respect. EVIDENCE: Three of the people’s care planning records 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 person. Since the last inspection the care plans have been changed, the new records are clearer and it is easier for staff to assess the information. Oakleigh Retirement Home DS0000066814.V339740.R01.S.doc Version 5.2 Page 11 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. This is good practice as staff have access to all the up to date information on each person allowing them to give the best care. Assessments on daily living were available as were risk assessments relating to mobility, mental and physical needs. On all the care plans the information was good this is an improvement on last year where some shortfalls were seen. There continues to be 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. People continue to say that 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. On observing the staff caring for people this was done in a way that protected peoples dignity. Care tasks were done in private staff spoke to people respectfully and were seen to knock on doors before entering people’s bedrooms. Communication is good and staff inform relatives if the health and well being of their relatives change. The policies and procedures relating to the recording and administration of medications is safe and are available to staff. The practice of passing medication from one staff to another to give out was not seen at this inspection. This is good practice as it as it reduces the risk of mistakes. Oakleigh Retirement Home DS0000066814.V339740.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 and 15 People using the service experience adequate quality outcomes. This judgement has been made using available evidence including a visit to this service. The home is aiming the activities towards the abilities of the people, diversity is being addressed in some activities but individual needs are not being met. Staff have looked at the way they address the needs of individuals at meal times to make sure everyone has the opportunity to eat their meal when it is hot. EVIDENCE: There continues to be a high number of people suffering from dementia related illnesses. Activities are undertaken on a one to one service and in groups. The manager said they find out from people what they want to do in the way of activities and an activity book is to be developed. 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. Oakleigh Retirement Home DS0000066814.V339740.R01.S.doc Version 5.2 Page 13 Other activities include walks, singing, exercise to music and for a small number of service users gardening. People’s pastimes are written in the care plans but this is not reflected in the activities that are offered in the home. Therefore people’s diverse needs are not being met unless they happen to fit into the activities offered. This is not good practice. There are no staff employed to develop social activities. Socialisation and takes second place to the physical care offered. This is not good practice as the social needs of people should be as important as physical and mental needs. People continue to 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 continues to be a number of people who need their food liquidised this was given through a feeding cup. The manager has split meal times so that the staff have the time to assist people with eating. I recommended that the registered person look at the staffing levels to make sure there are sufficient staff in the home at peak periods such as meal times. Oakleigh Retirement Home DS0000066814.V339740.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 and 18 People using the service experience adequate quality outcomes. This judgement has been made using available evidence including a visit to this service. People are protected by the complaints procedure and by the policies but training relating to adult protection needs to be improved. EVIDENCE: There continues to be a copy of the complaints procedure in each person’s room. The procedure is easy to follow and informs the individual how to complain and who to complain to. This is good practice. There has been on complaint since the last inspection this was investigated effectively by the homes management. Since the last inspection the recording of complaints has much improved. This is good practice as it is evidence that the home takes complaints seriously and records them effectively. People 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. Some staff need to undertaken training in adult protection. Oakleigh Retirement Home DS0000066814.V339740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24 and 26 People using the service experience good quality outcomes.. This judgement has been made using available evidence including a visit to this service. The environment is safe in a good state of repair and comfortable for the people who live there.. EVIDENCE: The home continues to be a safe and well-maintained environment there are aids and equipment to meet the needs of the residents. No maintenance staff permanently sited at the home and now shares with other homes in the group. The registered person must make sure that staff are readily available to maintain the home and are available in emergencies. Oakleigh Retirement Home DS0000066814.V339740.R01.S.doc Version 5.2 Page 16 On touring the building there were sufficient numbers of bathrooms and toilets within easy reach of communal areas. There is evidence that people have the opportunity to personalise their rooms with furniture and personal possessions ensuring individuality and ownership. This is good practice. People were generally happy with their rooms and said they can enjoy their own privacy if they wish. Since the last inspection maintenance work has been done to the water system and there is hot water to all rooms. 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 Retirement Home DS0000066814.V339740.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes. This judgement has been made using available evidence including a visit to this service. The mix of staff meets the needs of people, the skills do not meet their need. People are protected from potential abusers. 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. There are no staff undertaking NVQ training the registered person must make sure that this training is offered to all staff and new staff when employed. It was also noted that staff needed to be updated in Health and Safety, Moving and Handling, Basic Food Hygiene and Fire. This is not good practice, as staff need to keep up with up to date procedures relating to these subjects. Staff have received observational training in medication administration. The manager did this to make sure that staff gave out and recorded medications correctly did this. Oakleigh Retirement Home DS0000066814.V339740.R01.S.doc Version 5.2 Page 18 Many of the people have either a mental illness or a dementia related illness but there has been no training in theses areas. I recommended that the registered person should look for training in both these areas to make sure that the staff have the appropriate skills to give good care. Staff have also received information packs on specific subjects such as diabetes, basic wound management, continence, strokes Alzheimer and MRSA This is good practice 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 and have improved since the last inspection and Criminal Records check were available for all staff. All staff continue to undertaken an induction period and had a training and development plan. Oakleigh Retirement Home DS0000066814.V339740.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36 and 38 People using the service experience adequate quality outcomes. . This judgement has been made using available evidence including a visit to this service. A competent person manages the home but the home is not run in the best interests of people who live there. People staff are kept safe by the health and safety policies and procedures. EVIDENCE: The manager of the home has a nursing qualification and is trained to NVQ level four. She has managed the home for some time and has a good knowledge of the management systems in the home and the needs of the people who live there. Oakleigh Retirement Home DS0000066814.V339740.R01.S.doc Version 5.2 Page 20 The managers style is open and transparent and the views of people 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 quality assurance policies should be developed to include getting information back to people who have commented about the service. This is evidence that the registered provider and manager other people’s views and that people who live in the home are involved in the development of the service. The homes policies and procedures are reviewed effectively in line with current practice. The records relating to the residents fiancés are up to date easy to follow and transparent and it is the responsibility of the manager to audit these. I recommended that the responsible person should carry out and audit periodically to take some of the responsibility from the manager. The manager must prioritise the supervision of staff if people are to benefit from the staff development. Staff supervision records must be kept securely in the home There is a clear health and safety policy. There are records of checks for essential supplies such as gas electric and water. Since the last inspection the fire system been tested regularly and fire drills have been undertaken. Maintenance to hoists and bath aids are up to date. Oakleigh Retirement Home DS0000066814.V339740.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 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X 3 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 2 2 X 3 Oakleigh Retirement Home DS0000066814.V339740.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 OP30 Regulation 18(1) Requirement The registered person must make sure that staff given the training to enable them to meet the needs of the people in their care. Timescale for action 31/10/07 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 5 6 Refer to Standard OP5 OP14 OP27 OP33 Good Practice Recommendations Where people visit the home before admission details of any assessment should be written in the care plan. The social activities of the home should meet the needs of the diversity of people as an individual. The home should make sure there are sufficient numbers of staff on duty during peak periods such as meal times. A system should be developed where information and action taken relating to people’s views on the service can be fed back in an informative way. Where the home holds people’s personal monies, someone other than the homes manager should audit these. All confidential information relating to staff should be held in a secure place. DS0000066814.V339740.R01.S.doc Version 5.2 Page 23 OP35 OP36 Oakleigh Retirement Home Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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