Inspection on 04/07/05 for Oakwood Court

This inspection was carried out on 4th July 2005.

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 Court 27/10/06

Oakwood Court 12/01/06

Oakwood Court 22/10/04

Oakwood Court 17/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Oakwood Court Amberley Close Haywards Heath West Sussex RH16 4BG Lead Inspector Mrs KMS Leppard Announced 4 July 2005. V227019 th 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 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 Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Oakwood Court Address Amberley Close, Haywards Heath, West Sussex RH16 4BG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01444 458872 01444 458872 Sussex Housing and Care Mrs Ivy Mills Care Home (CRH) 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22 October 2004 Brief Description of the Service: Oakwood Court is a care home registered to provide care and accommodation for 33 service users in the category OP (older persons, not falling within any other category). The home is located on the edge of Haywards Heath town centre, close to shops and facilities offered by the town. The home was opened in 1992 and consists of a two storey purpose built building with extensive, well maintained gardens. A lift facilitates access to both floors. All bedrooms, except one provide single accommodation. All individual accommodation provides en suite facilities comprising a level access shower, toilet and wash hand basin. Sussex Housing and Care are the registered providers of Oakwood Court. The responsible individual on behalf of the organisation is Mr. A K Stewart Roberts and the registered manager of the service is Mrs. Ivy Mills. Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and was conducted on Monday 4th July 2005 between 9am and 6pm. Prior to the inspection thirteen resident and one relative/visitor comment cards had been received. The inspector spent time talking with small groups of residents in the lounge and sat with three residents for lunch. In total the inspector spoke with thirteen residents in groups and individually about their experiences of living in Oakwood Court. Comments received on the day and on comment cards have been incorporated into this report. The registered manager accompanied the inspector on a tour of the building and three staff spoke with the inspector, staff were helpful and open in their feedback. What the service does well: What has improved since the last inspection? What they could do better: Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 6 Priorities for Oakwood Court following this inspection are in relation to; • Ensuring that risk assessments include all actions being taken to minimise identified risks to residents. • Improving the recruitment procedure to protect residents. • Ensuring staffing levels reflect the needs of the residents at all times. 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 Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 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 standard(s) 3 & 5 Residents are assessed before they begin living in Oakwood Court. Residents and their families are facilitated to visit the home. EVIDENCE: Records for two new residents showed that they had been assessed before they began living in Oakwood Court. The registered manager had done one of these assessments whilst the prospective resident was visiting the home to look around. New residents who spoke with the inspector said that they or their relative had been able to look around the home and one visitor explained that her relative was staying in the home on a trial basis initially. Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 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 standard(s) 7, 8 & 10 The new care planning system comprehensively sets out residents needs. Resident’s health needs are met with the support of health care professionals. Resident’s privacy and dignity is respected. EVIDENCE: The staff at Oakwood Court have continued their hard work to implement a new care planning system. The records are comprehensive and provide a good standard of information about individual resident’s needs. Care records include a general risk assessment and assessments in relation to the risk of pressure areas and nutrition. Risk assessments need a little work to ensure they include all of the actions that are being taken to minimise risks that have been identified and ensure the safety and well being of residents. Residents sign their care records monthly as an indication that they have been shared with them. However, the homes own quality assurance exercise indicated that despite this not all residents were aware of their care plan when asked about it. The registered manager is aware that a review of what records are called and how they are explained is needed to resolve this. Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 10 Residents weight and input from health professionals is recorded. One resident who spoke with the inspector explained that she had community nurses visiting regularly to manage a leg ulcer. Staff who spoke with the inspector said that they receive good support from the local community mental health team to monitor resident’s health and well being to ensure that Oakwood Court remains a suitable placement. All of the residents who completed a comment card said that their privacy was respected. Some residents who spoke with the inspector talked about their preferences in relation to spending time resting and relaxing in their rooms and said staff respect these choices. Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 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 standard(s) 12, 13 & 15 Activities are provided. Residents are facilitated to maintain contact with friends and family. The menu is varied and residents are offered a choice of food. EVIDENCE: Activities provided for residents regularly include gentle exercise sessions and church services, the occasional game of bingo and more recently residents had potted plants in containers, which were displayed in the garden. Residents spoke highly of the piano player who visits the home and told the inspector about an occasion recently when he visited and played during supper whilst staff dressed up to serve the meal and residents dressed for dinner also. Six of the thirteen residents who completed a comment card were of the opinion that suitable activities are provided. Five residents felt sometimes this was the case. Staffing levels should be reviewed to ensure sufficient staff time is allocated to activity provision. Residents who spoke with the inspector said that visiting is flexible and that their relatives are welcomed into the home. One resident said she had a visitor coming who would be staying for the night and eating meals with her during her visit. Oakwood Court has a guest room to facilitate friends and family to Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 12 stay in the home. One visitor said she was always welcomed into the home and offered refreshment. Of the thirteen residents who completed a comment card, nine said they enjoyed the food and the remaining four said sometimes they enjoy the food. Residents said that they had choices offered to them and generally feedback about the food was positive. The inspector ate lunch in the home and noted that residents serve their own vegetables. One resident said this was good because you could have as much or as little of what you like. The inspector was pleased to note that complaints and positive comments about the food had been recorded and the chef had discussed many of them with residents. Residents had recently requested a cold meat and pickle meal, which they said they enjoyed. Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 & 18 Complaints are listened to and recorded. Residents are protected from abuse. EVIDENCE: All of the thirteen residents who completed a comment card know who to speak to if they are unhappy with their care. The complaints recorded in the last twelve months are in relation to food and have been referred to the chef, the records shows that he takes action including, discussing issues with residents and making changes to the menu. Two senior staff discussed adult protection training that they had recently attended and a newer member of staff talked about abuse awareness training that had been provided. All staff were enthusiastic about the learning these sessions had afforded them and the insight it had given them into their practise. The newer member of staff was aware of the reporting procedure. Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 20, 24 & 26 The environment is safe and well maintained. The home exceeds the communal space standard and individual accommodation is en suite. The home is clean and hygienic. EVIDENCE: The home meets the requirements of the fire service and plans are in place to ensure that the home is improved and well maintained. The recommendations of the occupational therapist’s report have been addressed. A variety of indoor and outdoor communal space is provided. Residents told the inspector that they use the garden for walking and relaxing. Residents are encouraged to furnish their rooms with their own belongings and each room is fitted with an en suite comprising toilet, wash hand basin and levels access shower. Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 15 Domestic staff are employed to maintain the cleanliness of the home and to manage laundry. The homes own quality assurance exercise carried out last year identified laundry as an area that needed improvement. One resident commented positively on how clean the home was and that her laundry is returned to her room for her to put away. Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30. The staffing levels could be improved to ensure they are consistently reflective of the needs of the residents. The homes recruitment process must be improved to ensure the protection residents. Staff are trained to do their job. EVIDENCE: Some resident feedback indicated that the home is short staffed. The rotas provided show that in addition to the registered manager and her deputy, the morning shift is covered by three care staff and the afternoon shift is covered by two or three, when two staff are on duty in the afternoon a third often comes on duty between 5 and 9pm. Two waking staff cover the night duty. Senior staff also operate an on call system to ensure staff can access support at all times. Staffing levels should be reviewed on the basis of residents needs to show that these can be met by the home at all times, taking into consideration that care staff also provide activities for residents and need sufficient time to ensure an appropriate programme can be provided. Records of recruitment were seen in relation to two new care staff. These did not include a CRB and PoVA disclosure obtained by the home before the member of staff commenced employment. The registered person must ensure Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 17 that the home’s recruitment process includes obtaining a CRB disclosure and PoVA check before employment commences to ensure the protection of residents. The same recruitment process should also be applied to volunteers providing a service to the home. A newer member of staff is completing TOPSS induction and foundation workbooks. The home’s own induction is also completed and this includes an induction to the fire system and procedure. The home’s training plan is comprehensive and staff are supported to undertake health and safety and specialist training including dementia, the home is also due to have a lecture provided by a continence advisor. Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 38 An annual quality assurance exercise is undertaken with residents to obtain their views of the service. The health, safety and welfare of residents is promoted and protected EVIDENCE: The home’s annual quality assurance exercise has recently been undertaken, this involved a committee member coming into the home and meeting residents to ask them for feedback about the service. The registered manager has identified areas for some work but as yet results have not been compiled for the purposes of sharing them with interested parties. The registered manager should ensure that this is done and that the Commission for Social Care Inspection receives a copy of the results and the annual development plan for the home. Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 19 The health, safety and welfare of residents is protected by the regular servicing of equipment in the home and the recording of accidents. Audits are now being undertaken monthly of the number of accidents and incidents occurring each month, falls are also recorded in care records. Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 4 4 x x 3 x 3 STAFFING Standard No Score 27 2 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x x x x 3 Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 21 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 29 Regulation 19(1) Requirement Staff records must include the information and documents specified within Schedule 2. Timescale for action 4th August 2005 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. Refer to Standard 7 27 Good Practice Recommendations It is recommended that risk assessments include all of the actions that are being taken to minimise risks that have been identified It is recommended that staffing levels be reviewed on the basis of residents needs to show that these can be met by the home at all times and taking into consideration that care staff also provide activities for residents Oakwood Court H60-H11 S14647 Oakwood Court V227019 040705 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY 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. 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