Inspection on 03/02/06 for Oaks The

This inspection was carried out on 3rd February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Oaks The 22/05/09

Oaks The 14/05/07

Oaks The 27/06/05

Oaks The 04/01/05

Oaks The 29/07/04

Oaks The 02/03/04

Similar services:

Carentan House

Ravensworth Lodge

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

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

CARE HOMES FOR OLDER PEOPLE Oaks The Hartrigg Oaks Haxby Road New Earswick York North Yorkshire YO32 4DS Lead Inspector Anne Prankitt Unannounced Inspection 3rd February 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 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. Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Oaks The Address Hartrigg Oaks Haxby Road New Earswick York North Yorkshire YO32 4DS 01904 750700 01904 752225 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) Joseph Rowntree Housing Trust Mrs Susan Jacqueline Davies Care Home 42 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (42) of places Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The registration of dementia care be for a maximum of 2 years to allow the new facility to be commissioned. That staffing levels do not fall below the appropriate numbers of the previous regulatory authority as in the enclosed matrix. 27th June 2005 Date of last inspection Brief Description of the Service: The Oaks forms part of the facilities in the Hartrigg Oaks retirement village in the village of New Earswick on the outskirts of York. The Oaks is a purpose built home able to care for up to 42 older people, which may receive a nursing service. The home is also registered to care for up to 11 service users with dementia care needs. Attached to the complex are a number of facilities including a gym, restaurant, coffee shop, library, shop and hydro therapy pool which can be used by service users from the home and the retirement village. Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection lasted for seven hours. Three hours preparation took place prior to the inspection. Those core standards which were assessed, and which met or exceeded the standard at the last inspection, were not looked at during this inspection. The registered manager was available during the course of the inspection. She was provided with feedback at the close. During the course of the inspection some service users, staff and relative were spoken with. Observation of care practices was made where appropriate. Some records were looked at, including service users’ monies, health and safety maintenance records, staff recruitment files and accident book. An inspection of the communal areas was made, and a sample of private accommodation. What the service does well: The home provides good quality accommodation for residents. There is a range of facilities that residents may choose to use. The home is spotlessly clean. There is an enclosed garden which residents may access with ease. There is an area of the home which provides care especially for people with dementia. It has an activities room and parlour. An activities person works closely with residents who live at the home. The residents of the home know the registered manager well, and appreciate her input. Staff at the home take pride in their work. Residents who commented were positive about their care, and their comments included: ‘I am very happy and satisfied’, ‘I am happy that staff understand my care needs’, ‘I am working with staff currently about my care plan’. There are a range of complimentary treatments, such as aromatherapy and reflexology, as well as a health activity centre, which residents are able to access if it is safe for them to do so. Residents are happy that they are able to make choices about the way they spend their time and live their life at the home. Residents can enjoy visits from friends and relatives whenever they wish. Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 6 Staff know that they must report any concerns about the vulnerability of residents. Staff receive training to help them in the care that they provide to residents. The trust seeks the views of residents about the service that they receive, so that any improvements needed can be acted upon. 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. Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 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 Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 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): 6 EVIDENCE: Standard 6 is not applicable. The registered manager confirmed that the home does not provide intermediate care. Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 9 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 and 9 Service users’ care needs are reviewed and access to health care services enabled. However, confirmation that reviews of individual risks are completed with the review of the care plan would assist in ensuring that any change in risk is easily identifiable. EVIDENCE: Care plans provided some good information which explained to staff what care was needed for individual service users. For service users who were recently admitted, there was evidence available to confirm that the care plan was in the process of being developed. One service user was clear that they felt involved in the development of the care plan, which was important to them. Service users have a key worker. Good daily records are kept, and contact with other professionals and relatives recorded. The health needs of service users are considered, and referral is made to the appropriate professional as issues arise. The home no longer accepts outside referrals for those prospective service users who suffer from dementia. Referrals are taken only from the surrounding bungalows within the retirement village. Therefore the needs of prospective service users are often understood prior to admission to The Oaks. The registered manager was in the process of making a referral for one service Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 10 user for assessment by a care manager where the home’s ability to continue to meet needs has been questioned following a period of in house assessment. The care plan for this service user needed update to reflect current holistic needs, and in order that it was maintained to the same standard as others seen. Risk assessments are completed. However, it was not recorded in all cases that they were reviewed along with the care plans, for example with regard to arrangements for service users who choose to self medicate, in order that the service user understands the importance of keeping their medication locked safely away in the facilities provided, or where moving and handling issues were identified. It is important that the latter be reviewed, to ensure that staff approach to moving and handling is consistent, and to avoid the possibility of inappropriate lifting techniques being adopted. In support of this, the registered manager stated that through appraisals they had become aware of this issue, and that the resources of the service were not being consistently used, therefore additional moving and handling training had been organised for all care staff. Chair exercises are offered on a weekly basis, and there is also a physiotherapy room. Complimentary treatments are also available for service users, such as reflexology, aromatherapy and massage. Service users’ comments included that they were ‘very happy and satisfied with the care’, ‘staff are marvellous; they always come quickly when I need them’. Trained nursing staff administer medication for service users admitted for nursing care. The registered manager stated that senior care staff who have completed medication training administer medication for those service users who are admitted for personal care only. The medication records were generally well kept. However, in the case of one service user, the administration records had not been signed when the medication had been administered. This issue was raised at the previous inspection. A second member of staff witnesses the recording of the administration of controlled medication, and those records audited could be reconciled with stock held. Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 11 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): 13 and 14 Service users’ rights to make choices and to maintain contacts with friends and family is respected and upheld. EVIDENCE: Service users were unanimous that there was sufficient flexibility at the home to allow them to make choices in their daily lives. There are a range of activities that service users may choose to join within the home to assist in fulfilling their social needs, including arts and crafts, health activity centre, spa pool, library, music room and shop. In addition, many of the people who live in the surrounding bungalows are known by the service users, and access The Oaks on a regular basis. This assists in maintaining previous friendships. Service users and a visitor confirmed that there were no restrictions placed on visiting. There is a residents committee, and one service user acts as representative on behalf of others who live at the home. Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 12 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): 18 Service users are protected by an open culture which informs staff of their responsibilities where abuse is suspected. EVIDENCE: Staff receive training about abuse awareness during induction. Staff were clear that it would be their duty and responsibility to report any matters relating to suspected or alleged abuse in order to protect the service user concerned. Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 13 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): EVIDENCE: None of the standards were assessed at this inspection Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 14 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): 28,29 and 30 The emphasis on the provision of training assists staff in providing care for service users. Systems in place prior to the deployment of staff need to be uniformly robust to ensure that service users are protected from unnecessary risk. EVIDENCE: The home is committed to the provision of training to NVQ Level 2 and above. There are two work based assessors who work at the home and who assist in this process. In addition to this, there is a training programme in place which covers statutory training and also training to assist staff in meeting the needs of those who live at the home. This includes four specialist training sessions in dementia awareness for each staff member. Training in challenging behaviour is also provided. Training update in moving and handling was organised. Representatives from the university also provide some training support to staff. The recruitment files of three appointed staff were inspected. In each case, two written references had been obtained prior to their deployment. However, in one case, the POVAFirst check request had been returned, as the CRB application had not yet been received. Whilst the registered manager explained that the staff member had been employed previously at the home when a CRB check was obtained, the staff member had been deployed on this occasion prior to the newly applied for CRB and POVAFirst check having been obtained. Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 15 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): 33,35 and 38 Services at the home are regularly reviewed, which helps promote better outcomes for service users. EVIDENCE: There are systems in place in order that the quality of the service can be measured. Questionnaires are sent on an annual basis to service users, and the information used as part of the quality review. In house audits take place, for example of the care plans and medication system. In addition, a representative from another home belonging to Joseph Rowntree Housing Trust carries out an external audit of the service. Results of questionnaires are published, and a copy sent to each service user. The registered manager stated that the most recent audit confirmed that the home excels in the provision of activities. Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 16 The home can safe keep personal monies on behalf of service users. The records of three service users were audited, and these could be reconciled with monies held. Service users are able to keep money in the lockable facilities provided in their room, should they wish to do so. A number of records relating to the maintenance of health and safety systems were seen, and evidenced that the home is kept maintained. The most recent visit from environmental health concluded that the systems within the kitchen were very good. The following matters were discussed with the registered manager: • The sluice room was unlocked, and contained a source of very hot water and a sluicing machine. The room was also used for the storage of linen skips. The need to complete a risk assessment was discussed, to ensure that service users were not subject to unnecessary risk should they enter the room. The registered manager has subsequently provided feedback that it is intended that valves will now be fitted in order that the hot water supply can be regulated. She has assessed that service users are not at risk from the sluice machine and the equipment stored within the room, and that the door will therefore remain unlocked. Until such time that the regulating valves are fitted, service users must be protected from unnecessary risk. The most recent gas landlords certificate stated that ‘the kitchen extraction is not interlocked with the gas supply’. The manager has provided feedback subsequent to the inspection that she has spoken to the health and safety representative for the trust. He has stated that the system at the home was in place prior to the regulation being introduced, therefore the information is classed as a recommendation only. However, the engineers for the trust are currently in the process of looking at the matter. The registered manager confirmed that the trust maintenance department maintain both the fire alarm system and the nurse call system on a regular basis. • • Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 17 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 1 Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? YES 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 OP29 Regulation 19 Schedule 2 Requirement Timescale for action 03/02/06 2 OP38 13 In any future appointments, a Criminal Records Bureau check must be obtained prior to the deployment of staff within the home. In exceptional circumstances where the registered provider has made the decision to deploy a staff member prior to the return of the disclosure, the registered provider must request a POVA First check which must be completed before the staff member commences duties. Service users must be kept 03/02/06 protected from unnecessary risks associated with the sluice room until such time that suitable safety measures can be put into place. Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 19 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 The risk assessments should be signed upon review on a regular basis, and preferably at the point at which the care plan is reviewed each month, to include in particular: • • • Falls risk assessments. Waterlow risk assessments. Risk assessments for service users who choose to self medicate. The care plan and associated risk assessments discussed at the time of the inspection should be reviewed to ensure that: Social needs, and how they can best be met are understood and recorded. • Risk from inconsistencies and potential inappropriate lifting technique is minimised. The registered manager should introduce additional safety systems to ensure that medication is signed for at the point of administration. As part of the risk assessment, service users who self medicate should be reminded that they must keep their medication locked away. • 2 OP9 Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Oaks The DS0000027974.V279471.R01.S.doc Version 5.1 Page 21 - 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. 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