Inspection on 12/09/07 for Oakwood

This inspection was carried out on 12th September 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

Oakwood 28/11/06

Oakwood 17/02/06

Oakwood 15/11/05

Oakwood 14/03/05

Oakwood 26/07/04

Oakwood 23/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Oakwood Radcliffe Park Crescent Radcliffe Park Road Salford M6 7WQ Lead Inspector Elizabeth Holt Unannounced Inspection 10:00 7 and 12th September 2007 th 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 Oakwood DS0000006717.V339013.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. Oakwood DS0000006717.V339013.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakwood Address Radcliffe Park Crescent Radcliffe Park Road Salford M6 7WQ 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) 0161 745 8119 0161 745 8840 maggie@raja.co.uk Mr M.K. Raja vacant post Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (29), Physical disability (1) of places Oakwood DS0000006717.V339013.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Minimum staffing levels as specified in the notice issued in accordance with Section 25(3) of the Registered Homes Act 1894 on 20 May 1991 shall be maintained. The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. One named service user is currently accommodated who is under 65 years of age. When this person leaves or reaches the age of 65, the category will revert to OP for people over 65 years of age. 28 November 2006 Date of last inspection Brief Description of the Service: Oakwood Hall Nursing Home is a care home providing nursing care for up to 30 older people. Oakwood is a large Victorian house situated in its own grounds at the end of a cul-de-sac within a quiet residential area of Salford. The home is close to Hope Hospital. The accommodation is provided in a combination of double and single rooms over two floors. The dining room is situated in the basement. A passenger lift allows access to all floors. The home is close to local facilities and it is close to the Motorways. There is adequate car parking space at the home. The weekly fees are from £364.41-£420.00. Extra charges are made for hairdressing, chiropody and magazines. Oakwood DS0000006717.V339013.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. These visits were undertaken as part of a key inspection, the first visit was on the 7th September 2007 and the second visit on the 12th September 2007. The inspection lasted for nine and a half hours overall. The home did not know the inspector was going to visit. During the course of the visit time was spent talking to several residents, relatives and the staff at the home. Throughout the visit observations were made of care practices and records and a partial tour of the premises took place. The home has a manager in post however an application to be registered with the Commission for Social Care inspection has not yet been made. A self-assessment survey information form (Annual Quality Assurance Assessment) had been completed by the office manager and home manager jointly and was received before the inspection. Residents and their families completed eight service user survey forms and five staff surveys were returned to the Commission. There have been no complaints, concerns or allegations made directly to the Commission in relation to this home since the last inspection. The term preferred by the people consulted during the visit was “residents”. This term therefore, is used throughout the report when referring to the people living at the home. What the service does well: The manager or a senior member of staff carries out assessments of prospective residents before the offer of a place is made to make sure the home can meet the resident’s needs. Residents and relatives are encouraged to look round and ask questions about life in the home. The residents looked well cared for and from observations made during the visits the staff were seen and heard to be kind and caring in their manner with the residents. Residents who could express a view said the staff were, “kind and helpful”, “caring and thoughtful” and “very good”. The home has an open visiting policy and relatives were seen to visit during the two visits. Relatives feel the manager will listen to them if they raise any concerns and they do their best to provide a good level of care. A choice of meal was available at each mealtime and the residents said they enjoyed the food provided. Oakwood DS0000006717.V339013.R01.S.doc Version 5.2 Page 6 The residents have choice about their daily routines and residents were seen to be supported in ways to promote their independence and dignity. The home encouraged the staff to undertake study days and courses and staff spoken to said they found the courses interesting and relevant. 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. The summary of this inspection report can be made available in other formats on request. Oakwood DS0000006717.V339013.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 Oakwood DS0000006717.V339013.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are given information about the home and have their needs and wishes assessed before they are admitted to the home. EVIDENCE: The home has both a Service User Guide (Residents Information) and a Statement of Purpose that provides new and existing residents and their families information about the services that the home provides. Copies of these documents were available in the residents’ bedrooms and in the entrance of the home. The files of three residents recently admitted to the home were reviewed and detailed pre-admission assessments were in place. A senior staff member carried out pre-admission assessments and admissions to the home would only take place if the manager was confident the assessed needs of the individual Oakwood DS0000006717.V339013.R01.S.doc Version 5.2 Page 9 could be met by the home. One resident who had recently moved into the home said, “I am happy with my room and am settling in well into the home, the staff are very kind and caring.” Another resident spoken to who had recently been admitted said she had visited the home before they offered her a place and she was settling into her new environment well. A resident’s son who was visiting his relative said, “I was shown around the home and was spoken to by the staff who were welcoming”. Residents who were admitted under Care Management arrangements had copies of assessment information held within their care plan. One resident confirmed she had received a written contract and a signed copy was held by the home. The home did not provide intermediate care. Oakwood DS0000006717.V339013.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A care planning system is in place that provides staff with information to satisfactorily meet the residents’ health and personal care needs. A shortfall in the procedure for the receipt of medication into the home has the potential to put residents at risk. EVIDENCE: A sample of care plans was looked at. Generally the care plans were detailed and gave staff the information required for them to carry out the care identified. The information gathered at the admission was detailed to provide staff of the care needs of the individuals. A discussion with the manager highlighted that she planned to improve the care planning system currently in use to be clearer. There was evidence that the plans of care had been drawn up with the involvement of the resident/relative where possible. Care plans showed how they promoted the privacy and dignity of individuals. Oakwood DS0000006717.V339013.R01.S.doc Version 5.2 Page 11 Improvements had been made to the recordings of the daily statements completed on each resident to reflect the nursing care provided to the residents. It was noted that when residents had been assessed as having a High Waterlow score, the care plan recorded the detail of the pressure-relieving mattress in place. The risk assessments and the monthly evaluations had improved to show changes over the previous month. It was good to see that one resident’s skin was dry and the care plan reflected how this had improved following the treatment plan. There was some social history, likes and dislikes and interests of the residents included in the information gathered to help the staff know the residents’ background. The system for checking medications into the home must be reviewed. A sample of medication administration records (MARS) was examined and these were generally accurately recorded. A shortfall was noted, as some of the drugs had not been signed on the medication administration record to show they had been received into the home. Controlled Drugs records were accurate and checked regularly by the Registered Nurses. From observations made during the inspection and discussions with members of staff, relatives and residents it appeared that the nurses and care staff treated the residents with respect and dignity. The residents looked appropriately dressed and it was evident the personal care needs of the residents were being attended to. One relative said that “the staff are very kind and attentive to me and my mother says the same”. A resident said, “ I am well cared for, they come and chat to me to check I am feeling all right”. The manager said, and the pre-inspection questionnaire confirmed, that there were no residents with pressure sores at the time of this inspection visit. Oakwood DS0000006717.V339013.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some activities were provided and residents were able to maintain contact with family and friends. Residents were encouraged to exercise choice over their lives and residents enjoyed the meals provided. EVIDENCE: A plan of activities was in place however it is noted that residents do vary in their wishes and capacity to be involved in activities. The entertainment and leisure activities provided by the home included aromatherapy, quizzes, bingo, reminiscence, games, videos, beauty sessions and music and movement. Some of the residents said they had enjoyed the summer fair. During the inspection residents were seen to be seated around the televisions for lengthy periods of time however staff were seen interacting on a one to one basis with the residents. Visitors were seen to be supported to talk to their relative in privacy or to take them into the grounds of the home for a change of scene. The home had an open visiting policy and relatives spoken to say they were made to feel welcome. One relative said, “I am always made to feel welcome and I find the home very friendly”. Oakwood DS0000006717.V339013.R01.S.doc Version 5.2 Page 13 Residents are given a choice of menu each day and the records were seen for this. Staff were seen talking to residents about what was for lunch and it was clear they knew their likes and dislikes well. The hot meal served at lunchtime looked appetising and residents spoken to said the food was “lovely and tasty”. Following a recommendation that use be made of the available dining room at the last inspection, the manager said this had been raised with the residents and the majority of residents preferred to eat in the lounge areas rather than going downstairs to the dining room. Some residents were supported to eat in the privacy of their room, as this was their preferred choice. Residents were seen to be assisted with their meals as needed in a supportive and dignified manner. The staff showed concern and care for residents by offering reassurances such as holding their hand, talking to them on a one to one basis or walking a short distance with them. Some of the residents received visits from the local clergy and received communion at the home as they wished. Oakwood DS0000006717.V339013.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place for managing complaints and to protect residents from abuse. EVIDENCE: The home had the policies and procedures in place which gave residents/relatives the information required to make a complaint. The home had received one concern, which had been dealt with appropriately. The atmosphere within the home is open and friendly. Guidance on the local multi-agency procedures were available for staff to refer to. A number of the staff have undertaken training in the protection of vulnerable adults. A care staff member could explain what she had learnt about the different types of abuse following the training and she felt it had raised her awareness of what signs to look for. Other staff spoken to knew what to do in the event of an allegation of abuse and said they would feel safe to whistle blow on any staff members. A training programme was in place for staff who had not yet received abuse awareness training. Oakwood DS0000006717.V339013.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, homely and comfortable environment with attention paid to the standard of décor. EVIDENCE: Following a brief tour of the premises, the home was clean, homely and comfortable. Residents’ bedrooms were clean, tidy and were personalised and contained residents’ personal belongings such as televisions and photographs. There are pleasant seating areas in the lounge and dining areas for residents to socialise. Residents who were able to express a view were pleased with their bedrooms. One resident said, “I haven’t been here many weeks but just look at my room, it’s lovely isn’t it”. A programme of maintenance is kept and the maintenance man was following a programme of redecorating the corridor on the first floor. Plans were in Oakwood DS0000006717.V339013.R01.S.doc Version 5.2 Page 16 place to replace the carpet on the first floor after the corridors had been repainted and decorated. Seven out of eight responses in the resident’s surveys showed that the home was “always fresh and clean”. The temperature of the home had been reduced since the last visit however this should be monitored further and action taken as some residents, relatives and staff stated they felt “uncomfortably warm”. Aids and adaptations are provided in bathrooms and toilets as required and information regarding the control of infection is available for staff. Oakwood DS0000006717.V339013.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the employment, training and support of staff ensure the needs of the residents’ are met. EVIDENCE: A staff group consisting of an administrator, cleaning, laundry, catering, maintenance and a part time activities organiser supports the nursing and care staff. Staffing levels on the days of the inspection visits appeared sufficient to meet the care needs of the residents. A number of the staff have worked at the home for a number of years, which helps to provide continuity of care for the residents. Three staff files were looked at and each one contained completed application forms, written references, proof of identification and evidence to show checks had been undertaken by the Criminal Records Bureau. At the start of employment staff receive training in moving and handling, fire safety and then attend the Skills for Care induction programme within their first six to twelve weeks. The two chefs employed have achieved the National Vocational Qualification in professional cookery. The information provided to the CSCI showed that other training courses staff had attended since the last inspection included dementia awareness, cultural Oakwood DS0000006717.V339013.R01.S.doc Version 5.2 Page 18 awareness and moving and handling. The home employed 21 care workers with 13 members of staff having successfully completed the National Vocational Qualification 2 award. Staff members spoken to were enthusiastic about their training and development and felt the home did support them. One staff member responded in the survey stating, “the staff are kept well updated with courses and ongoing training”. Visitors to the home said the management and staff are very approachable and felt they could easily discuss their relative’s/friend’s care with them. Oakwood DS0000006717.V339013.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, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, welfare and safety of residents was promoted. EVIDENCE: Since the last inspection the home have appointed one of the existing Registered Nurses as the manager with support from the experienced office manager to carry out this role. The manager has thirty-eight years experience in the Nursing Profession and is able to provide time as a “hands on” manager because of the support provided by the office manager. A requirement was made for the manager to apply to the CSCI to become the Registered Manager, which she plans to do. It was clear from the discussions with the manager that she creates an open and friendly atmosphere and that staff, residents and relatives find her approachable. Oakwood DS0000006717.V339013.R01.S.doc Version 5.2 Page 20 The manager must introduce a system to audit the medication system in the home to ensure the staff are following the policies and procedures in place. The home has a system in place to obtain the views of residents, relatives and visiting professionals. Responses from these are used to identify improvements for the residents. The home does not currently hold residents/relatives meetings currently as the staff considers they deal with individuals on a one to one basis. This should be considered as a way to include their views in future plans. Fire safety checks were carried out on a regular basis and the fire risk assessment had been updated. A record was available of a recent fire drill with a list of staff that had attended this. Accidents that occurred in the home were appropriately recorded with evidence to show these were reviewed to see if any changes to minimise the risk might be needed. Policies and procedures were in place to safeguard the residents’ financial interests; it is recommended that funds be held in interest bearing accounts and where possible relatives manage their relatives’ finances. Oakwood DS0000006717.V339013.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 X X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Oakwood DS0000006717.V339013.R01.S.doc Version 5.2 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Medication must be properly signed for when it is received into the home to ensure the residents receive their medication as prescribed. To ensure the home is appropriately managed, the manager must submit an application to the Commission to become registered. Timescale for action 19/10/07 2. OP31 9 30/11/07 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. Refer to Standard OP25 Good Practice Recommendations It is recommended that the temperature of the home be monitored to ensure it is at an ambient temperature. Oakwood DS0000006717.V339013.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oakwood DS0000006717.V339013.R01.S.doc Version 5.2 Page 24 - 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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