Inspection on 01/03/06 for Oakwood House

This inspection was carried out on 1st March 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 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 House 16/09/08

Oakwood House 20/09/07

Oakwood House 05/09/06

Oakwood House 14/11/05

Oakwood House 07/03/05

Oakwood House 19/10/04

Oakwood House 17/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

SignHealth

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Oakwood House 400a Huddersfield Road Stalybridge Tameside SK15 3ET Lead Inspector Steve Chick Unannounced Inspection 11:15 1st and 3 March 2006 rd 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 House DS0000005575.V280434.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. Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Oakwood House Address 400a Huddersfield Road Stalybridge Tameside SK15 3ET 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 303 2540 0161 303 2540 Mr Stephen Mycroft Ms Sheila Mannion Ms Sheila Mannion Care Home 18 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (18), of places Physical disability over 65 years of age (14), Sensory Impairment over 65 years of age (1) Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include up to 18 (OP); up to 14 (DE) (E); up to 14 (PD) (E) and up to 1 (SI) (E) 14th November 2005 Date of last inspection Brief Description of the Service: Oakwood House is an appropriately converted, large detached building, set back from a fairly busy main road. There are public transport links to the centre of Stalybridge. Oakwood House is owned by two people, one of whom is also the registered manager. It offers accommodation to up to 18 older people, on two floors, mainly in single bedrooms. There is one lounge and a large dining room. Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection three service users were interviewed in private, as was one relative of a service user. Additionally discussions took place with the manager and the other registered person. The inspector also undertook a tour of the building and scrutinised a selection of service user and staff records as well as other documentation, medication and maintenance records. This inspection was unannounced and not all standards were assessed. It is strongly recommended that this report is read in conjunction with the previous report from November 2005. What the service does well: What has improved since the last inspection? Some administrative areas have improved. The manager’s use of her time to address the full range of her responsibilities has been partially addressed. Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 Page 6 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 House DS0000005575.V280434.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 Oakwood House DS0000005575.V280434.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): 2. Service users are given appropriate information about the terms and conditions of their stay at the home so that they are aware of their rights and responsibilities during their stay. EVIDENCE: A random selection of service users’ files was scrutinised. All had a copy of the home’s terms and conditions. This was an improvement from the previous inspection. However, some examples seen, had the signature of the service user as evidence of acceptance of the terms and conditions, when other information on the file indicated they would be unlikely to have the capacity to understand those terms and conditions. Other examples seen had, more appropriately, a signature from a relative. The manager reported that no service user had been admitted on a permanent basis since the previous inspection. Consequently no evidence of service users Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 Page 9 being given written confirmation of the home’s ability to meet their needs was sought. Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9. Service users had written plans of care, but these were not reviewed regularly enough to ensure they accurately reflected their current needs. Medication procedures were not followed with sufficient rigour to guarantee the safety of service users. EVIDENCE: A selection of service users’ files was scrutinised. All had a copy of a written plan of care. Documentary evidence of the service user’s involvement in the care planning process was inconsistent. Some care plans were unsigned and undated, written evidence of monthly reviews of the care plan was well maintained for a period, but this was not sustained. Similarly there was evidence of appropriate written risk assessments, for example in connection with a service user who was administering their own Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 Page 11 medication, but no documentary evidence that the risk assessment had been reviewed. There was documentary evidence of periodic involvement of relatives or advocates in the more structured review process. All service users spoken to were positive about the way in which their care needs were being met. The small size of the home and the relatively stable group of care staff would help in ensuring appropriate care was being given in spite of the administrative failings. The home has an appropriate medication procedure which was not scrutinised at this inspection. Medication storage was predominantly appropriate, although the issue of the storage of the small amount of controlled drugs was reported by the manager as still being discussed with the home’s supplying pharmacist. Medication administration records presented as being predominantly appropriately maintained. However there was no record of any medication being administered on one morning, nor was there any record of an explanation being provided. Discussion with the manager indicated this, again, was an administrative oversight and not a failure to administer the medication. However, this was indicative of a failure to follow the home’s own medication procedure. Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 The home provides recreational activities based on the expressed wishes of service users. EVIDENCE: The manager reported a range of activities which happen periodically. These included Card Crafting at various times of the year; ad hoc reminiscence sessions; manicures; an entertainer every two months and occasional videos. The most valued ‘social activity’ was reported as being one to one chats. Service users spoken to expressed satisfaction with the social activities available. Spiritual needs are addressed by visits from a lay preacher from one Church attending every Sunday, and another Church visiting once a month. Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: None of these standards were assessed at this inspection. Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 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 the following standard(s): 19, 21, 23, 24, 25 and 26. The home is appropriately maintained, decorated and cleaned to enable service users to live in a pleasant, safe and hygienic environment. Suitable toilet and bathing facilities are available to enable service users to maintain their personal hygiene in a dignified manner. EVIDENCE: A tour of the building, including a random selection of bedrooms, identified no issues requiring remedial action. The home presented as being well maintained and decorated throughout. The décor and furnishings create a homely atmosphere. Service users’ bedrooms demonstrated an appropriate range of personalisation and were kept clean and tidy. The home was clean and tidy throughout, with no unpleasant odours. This was confirmed as the usual state of the home by service users and the visitor spoken to. Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 Page 15 Appropriate toilet and bathing facilities were provided. Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 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 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 and 30. Insufficient numbers of staff are motivated to attend NVQ training to improve outcomes for service users. EVIDENCE: Information provided by the manager demonstrated that three of the sixteen care staff had achieved NVQ II. This represents only 19 . It was also reported that three staff were undertaking the NVQ II and one was undertaking NVQ III. If all these staff are successful, this will still only result in 44 of the staff holding an appropriate qualification. The manager reported that these figures represented some staff’s reluctance to undertake the training, not a managerial reluctance to support them. The training records for three staff members was seen. These indicated that basic mandatory training such as moving and handling and first aid had been undertaken. Additional in house training was also offered, and some staff had attended a training course in connection with Dementia. Annual development plans for individual staff members were not available. As mentioned elsewhere in this report, service users who were spoken to reported very positively on the care they received from the staff team. Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 Page 17 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 and 38. Service users’ views are taken into account and influence the running of the home. Day to day working practices are appropriate to promote the health and safety of service users. The lack of rigorous and timely documentation restricts the transparency of the home and consequently inhibits service users’ ability to be fully confident in the home’s practice. EVIDENCE: Oakwood house has a potentially good and helpful Quality Assurance framework. Unfortunately there had been a delay in producing the latest annual report. The registered person reported that, in part, this was due to the Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 Page 18 home’s desire to ensure that service users who needed support to complete the questionnaire, had that support from people who were not likely to be biased in favour of the home. As mentioned elsewhere in this report service users were confident that their views were taken into account in the running of the home. There was documentary evidence of appropriate training for staff to maintain basic health and safety of themselves and service users. The record of accidents presented as being appropriately maintained. Observation confirmed the availability of disposable gloves to minimise the risk of cross infection. There was documentary evidence of appropriate maintenance contracts for the lift and hoist. Similarly records relating to the maintenance of appropriate fire detection and alarm systems presented as being appropriately maintained. Written risk assessments relating to the building and general work practices were not available for inspection. As with other aspects of administration which are important to underpin good practice, risk assessments relating to individual service users were not reviewed frequently enough. One example was seen where a written risk assessment had not been completed following an incident with one service user. Discussion with the manager indicated that risk factors had been considered and it was the documentary evidence which was lacking. Issues relating to the manager’s use of her time had been identified at the previous inspection. The manager and other registered person both confirmed that more of her time was now used to address administrative and managerial issues. While there was some evidence to indicate this was having a positive effect, administrative failures still undermined the good quality of care offered. Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 Page 19 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X 3 X 3 3 3 3 STAFFING Standard No Score 27 X 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 2 Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP9 Regulation 15 13 Requirement The registered person must ensure that individual care plans are regularly reviewed. The registered person must ensure that he home’s medication procedures are rigorously followed. The registered person must ensure that sufficient numbers of staff undertake the appropriate NVQ training. The registered person must ensure that individual staff members have a structured training program which reflects their assessed developmental needs. The registered person must ensure that an annual development plan is made available for service users and other stakeholders. The registered person must ensure that all necessary risk assessments are written and regularly reviewed. Timescale for action 01/05/06 01/05/06 3. OP28 18 01/10/06 4. OP30 18 01/07/06 5. OP33 24 01/07/06 6. OP38 13 01/05/06 Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 Page 21 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 OP2 OP38 Good Practice Recommendations The registered person should ensure that only service users who have the capacity to understand the terms and conditions are asked to sign them. The registered person should ensure that regular audits of administrative systems are undertaken. Oakwood House DS0000005575.V280434.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 House DS0000005575.V280434.R01.S.doc Version 5.1 Page 23 - 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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