CARE HOMES FOR OLDER PEOPLE
Oakwood Radcliffe Park Crescent Radcliffe Park Road Salford M6 7WQ Lead Inspector
Jackie Kelly Unannounced Inspection 15th November 2005 11:40 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.V257286.R01.S.doc Version 5.0 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.V257286.R01.S.doc Version 5.0 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 Mr M.K. Raja Margaret Evans Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 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. Three named individuals are accommodated for personal care only. If these people leave, the registration will revert solely to accommodation of service users requiring nursing care only. The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 14th March 2005 2. 3. Date of last inspection Brief Description of the Service: Oakwood is a care home providing nursing care for up to thirty older people. The home can also accommodate up to three people who do not require nursing care but need personal care only. The home is owned by Mr M.K. Raja and managed by Ms M. Evans. 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 accommodation is provided in a combination of double and single rooms over two floors. The dining room was situated in the basement; however a lift allows residents access to all floors. Local shops are within walking distance of the home and it is approximately five miles from Manchester City Centre. Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over half a day. Time was spent talking with the manager of the home Ms M Evans. A care worker, resident, cook, maintenance person and a relative were also spoken with during a tour of the home. Care plans, Criminal Record Bureau disclosures, and accident records were looked at. At the time of the inspection there were twenty-two people living in the home. The home would take residents for respite care if there were a bed available at the time of the request. The home had received a visit from the environmental health department and had been given the ‘Bronze Award’. However, there were a number of improvements identified which were in the process of being actioned. What the service does well: What has improved since the last inspection?
The accident forms now contain the home address of the care workers as required. The dining room was being refurbished; the decorating was completed and a new carpet was due to be laid. New lounge chairs had been purchased. Overhead tracking was to be installed in two of the bathrooms to enable
Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 Page 6 residents to have a bath safely. One of the shared rooms had been converted into two singles. 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. Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 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.V257286.R01.S.doc Version 5.0 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): 3 Prospective residents receive a full assessment that assures them their needs will be met. EVIDENCE: The manager had visited both of the last two people to be admitted into the home prior to offering them a place. The records, which included a preadmission assessment, were looked at and found to be satisfactory. One of these residents was spoken to, she confirmed that she had settled in and was happy with the care she was receiving and had no complaints. The home did not have any intermediate care beds. Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 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): 7,8,9. Residents’ health and personal care needs and privacy was being met. EVIDENCE: The care plans of the last two people to be admitted were looked at. They contained information, which would help the care workers to meet the needs of the residents. There were also records of visits by chiropodist and GP. It had been a requirement at the previous inspection of 14 March 2005 that the pre-printed risk assessments, which were being used, must be reviewed so that the needs and risks for each individual resident be reflected in the care plan and risk assessment. However, one of the risk assessments seen was a pre-printed version with the name of the resident inserted over the top of the word ‘resident’. Although this goes some way to individualise the risk assessment it is still not satisfactory and personal individual risk assessments must be done. None of the residents administered their own medication. Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 Page 10 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): 13,15. Family and friends were welcomed. Residents were not able to make choices from a menu. EVIDENCE: One of the most recent residents to be admitted to the home said that they visited their relatives twice a week. The previous report of the 14 March 2005 contained a requirement that residents must be given a choice from a menu and the size of portions must be increased and served on ‘normal size’ dinner plates. The manager said that the majority of the residents have their meals on appropriately sized plates. However, a number have a smaller plate, which is their choice. The size of portions served is as requested by the resident and reflects their choice and appetite. The menus had not been done and were still in the process of being developed, as were menu cards. The manager said that they were almost completed. All the staff had training in Basic Food Hygiene. Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 Page 11 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): 16,18 Residents were protected through the complaints procedure, and daily monitoring of care workers. However, staff needed to be appropriately trained in the area of protection. EVIDENCE: There had been one complaint during the past twelve months, which had been resolved. The letter sent to the relatives was seen and was well written; addressing the complaint made and offering further discussion if they were not satisfied. The manager had received training on the protection of vulnerable adults during a previous employment and was due to attend a seminar on the ‘safe guarding of vulnerable adults’. There were policies and procedures in place however, these were not looked at during this inspection. The manager was proposing to put together a handout for staff as none of the staff had received training other than that taken as part of National Vocational Qualifications. All staff should receive training on the protection of vulnerable adults. Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 Page 12 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): 19,22,24,26. The home was clean, maintained and decorated to a reasonable standard. The furnishings, fittings and equipment were for the most part in a satisfactory condition and suitable for the needs of the residents. EVIDENCE: A tour of the home took place. The bedrooms had been personalised and three bedrooms had been equipped with new wardrobe, bedside table and chest of draws. A number of new lounge chairs had also been purchased. Two of the bathrooms were to have overhead tracking fitted to enable residents to use the baths safely. One of the shared rooms had been divided to make two singles. The dining room was being refurbished and should be completed within the next few weeks.
Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 Page 13 There was a requirement in the previous inspection report of the 14 March 2005 that the divan beds must be replaced with adjustable beds. There was an action plan in place to purchase one or two a year; one had been ordered which will bring the total of adjustable beds to six. However should the present plan continue it would take between fourteen to twenty-eight years to complete the change. This is not acceptable and the owner must review the plan to increase the number of beds purchased within the yearly budget. Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 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): 27,28,30. Suitable, experienced and trained nursing and care staff were caring for the residents EVIDENCE: Care staff training is ongoing with a number of care workers having completed a National Vocational Qualification (NVQ) Level 2 or Level 3 with others in the process of doing their training. The care worker who was spoken with was happy with the care the residents received and the general management of the home. The manager was introducing a distance-learning package to train the staff in looking after residents with dementia care needs. Ten of the care workers were registered to do this. The Criminal Record Bureau disclosures for the staff was seen. No other staff records were checked at this inspection. Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 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): 31,35,36,37,38. The home was managed for the most part by a staff team who were trained, experienced and were aware of the health and safety of residents. EVIDENCE: Mr Raja, (the owner) visited the home regularly. Mrs Raja also attended the home twice a week in her capacity as operational manager. The manager, Ms Evans, had many years of experience of working in care homes, had a nursing qualification and was looking at doing a management course in order to comply with the national minimum standards. A regular formal staff supervision programme was not in place. The manager said that not all the senior staff had received training in conducting formal supervision. The manager was looking into obtaining a distance-learning package to meet this need. Formal staff supervision and annual appraisal, which records all training given, must be introduced.
Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 Page 16 The home had records in place for those residents who did not manage their day-to-day expenses. Those records seen on the day of the inspection were satisfactory unless otherwise stated in this report such as risk assessments. The home had received on the 10 November 2005 the Bronze environmental health award. However, there were a small number of requirements that had either been implemented or were being seen to. Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 3 X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 2 2 3 Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 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 OP7 Regulation 15 Requirement The registered person must ensure that individual risk assessments are in place. (Previous timescale of 14 March 2005 not met) The registered person must produce menus, which allow the residents to have a choice at meal times. (Previous timescale of 14 March 2005 not met) The registered person must improve the current action plan for the replacement of divan beds. (Previous timescale of 14 March 2005 not met) The registered person must ensure that all staff receive formal supervision and annual appraisal which includes a record of all training or induction received as stated in Schedule 4. The registered person must ensure that all records as required are in place. The registered person must ensure that all staff participate in training on the protection of vulnerable adults. Timescale for action 22/01/06 2 OP15 12 (2-3) 30/01/06 3 OP24 23 22/01/06 4 OP36 17 (2) 30/01/06 5 6 OP37 OP31 17 17 30/01/06 28/02/06 Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 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 OP31 Good Practice Recommendations The registered person should ensure that the manager undertakes a management course to comply with the national minimum standards. Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Oakwood DS0000006717.V257286.R01.S.doc Version 5.0 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. 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. You have been warned!
