Inspection on 17/01/07 for The Oaks

This inspection was carried out on 17th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Oaks 23/04/08

The Oaks 18/12/07

The Oaks 02/07/07

The Oaks 23/01/06

The Oaks 11/08/05

The Oaks 23/02/05

The Oaks 08/07/04

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 The Oaks Oak Avenue Hindley Green Wigan Greater Manchester WN2 4LZ Lead Inspector Sue Donovan Unannounced Inspection 17th January 2007 08:15 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 The Oaks DS0000005755.V315482.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. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Oaks Address Oak Avenue Hindley Green Wigan Greater Manchester WN2 4LZ 01942 521485 01942 522141 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) Mr Kevin Hall Mrs Denise Bostock Care Home 31 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (31), of places Physical disability (3), Physical disability over 65 years of age (8) The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for a maximum of 31 service users to include: up to 31 service users in the category of Older People (OP) up to 3 service users in the category of PD (Adults with Physical Disability) up to 8 service users in the category of PD(E) (Adults with Physical Disability over 65) up to 5 service users in the category of DE(E) (Adults with Dementia over 65) The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. The Home’s Manager, Senior Carers and Carers must be adequately trained to meet the specific needs of the individual service users with Dementia. The Statement of Purpose must be reviewed and updated to reflect the change to the registration. 23rd January 2006 2. 3. 4. Date of last inspection Brief Description of the Service: The Oaks is located in a quiet residential area of Hindley, close to the main bus route, local shops and amenities. Car parking for visitors is provided at the front of the home. The Oaks is registered to provide personal care services for up to 31 elderly service users, both male and female. Within the total number of 31 registered places, the home may accommodate up to eight elderly people with a physical disability, three people under the age of 65 who have a physical disability, and five people over the age of 65 with dementia or other cognitive impairment. The fee is currently £367.50 per week. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit took place over nine hours from 8.15am to 5.15pm. The home was not told the inspection was to take place. The report was written after looking at the information sent to the commission for social care inspection (CSCI) including comment cards (one from a doctor and one from a social worker) and after talking to some of the residents of The Oaks a relative, staff and the manager and looking around the home. During the inspection, assessment, care plans and medication records were looked at to make sure resident’s needs were being met. The inspector spent time in the lounge/dining room areas to see if they were clean and well decorated and to look at how the residents were cared for. What residents were served for lunch was looked at and the inspector saw how resident’s money and the home and equipment were kept safe. What the service does well: From speaking to residents it was clear they were happy with the care provided. Residents described staff as “good girls” “friendly girls” and “kind.” A relative said, “we love it, its relaxed here not regimented.” A good choice is available at mealtimes and the meals are varied, well balanced and nicely presented. Residents said “the foods good” “always a choice” and “meals are good.” Information that residents receive when they come to live at the home is detailed. Other information is provided in the reception area that may be useful to them and their relatives. Staff at the home receive training and the manager supervises her staff on a regular basis. The home is well maintained and safety checks are carried out when they should be. A social worker said that he had always found the manager to offer a very good service to people who require complex care. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Assessments (a record of what residents need help with) need to be filled in better to make sure the home will be able to care for residents properly. Residents that come to stay at the home for respite need to have a care plan and risk assessments. Records need to be completed on a regular basis. Complaints need to be fully investigated and the people who have complained replied to. The lounge area can be smoky. A new area for residents that smoke needs to be found. Activities need to be arranged on a regular basis for residents to join in if they wish. A resident said, “I am really bored, I like to be busy.” Clearer signs are needed around the home (all the toilet signs were different). So residents can find their way around better. The laundry needs to be more organised so residents get there own clothes every time and the laundry kept clean. The lounge/dining room carpet needs to be kept as clean as the rest of the home. Please contact the provider for advice of actions taken in response to this The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 7 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. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 8 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 The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information is given to residents and their families to enable them to make a decision as to the suitability of the home. Residents who move to the Oaks to live have their needs assessed to make sure these can be met. Residents receiving respite have less information and this may affect their care. EVIDENCE: A statement of purpose (SOP) and service user guide (SUG) was provided for all residents. The documents were displayed in the reception area of the home for all visitors to read. The detailed information includes for example, a description of the services and facilities, living in the home, making a complaint, privacy and dignity. The documents need to be updated to show the numbers, qualifications and experience of the staff and manager who work at the Oaks. It was discussed with the manager that the guide could be produced in a userfriendly format in larger print with pictures and symbols. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 10 A resident said that she had been given a ‘booklet’ when she had visited the home. A number of pre- prepared packs were seen in the manager’s office for people who may wish for information/details about what the home has to offer. Five residents files were looked at. Two files of residents who lived at the home long term held evidence of assessments by local authority care managers as well as senior staff at the home and this information was used when writing the care plans (the information that staff need to be able to meet residents needs). The three files of respite residents held insufficient information for staff to know the level of care the residents needed. Assessments were seen on the files but these were incomplete, unsigned and did not hold information already obtained by care managers. One care manager’s assessment said that X was at risk from falls but this was not on the information compiled by the home and no care plan or risk assessment had been written. The requirement at the previous inspection for a full assessment of care needs to be undertaken and recorded had not been addressed. Discussion took place regarding the assessment process that was undertaken prior to a person moving into or receiving respite at the home. The manager said that the prospective resident and their family are welcome to look around the home and spend time meeting other residents and staff and if needed senior staff would provide transport. The manager would visit the person at home or in hospital and an assessment of need drawn up. The interested parties can then make a decision whether admission to the home is appropriate. One resident confirmed that she had visited before moving into the home. A relative said, “I used to have a friend here, that’s why I choose the home for my mother,” “we love it, it’s relaxed here not regimented” and a resident said “there’s nothing wrong with this place,” “there friendly girls, very good.” The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 11 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, & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recording in care plans needs to be better if resident’s health and personal care needs are to be met. The medication system was safe ensuring the residents received their medicines correctly. Personal support is offered in away that promotes the resident’s privacy and dignity most of the time. EVIDENCE: During the last two inspections care plans were seen to be poorly maintained. Five files were examined. The plans of the two permanent residents had completed care plans that contained information about how the residents needed to be cared for. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 12 Completed care plans showed physical, mental health, personal care needs, how to promote independence and recorded actions to be taken to meet these needs. On one care plan the cultural needs and wishes in respect of terminal care had not been completed. The files contained night care plans but the observation sheet had not been completed on both files for sometime. The plans contained limited information with regard to personal information, one file had a completed life history section and had recorded that the resident ‘enjoys sport’. It was discussed with the manager the need to have more detailed information on every resident with regard to their life prior to living at the Oaks. The manager said she had asked the activities co-ordinator to compile these with residents and their families. These was found on the co-ordinators file for some residents and showed some good detailed information which included major life events, current and former lifestyle, current and former recreational activities and social networks. The sheets should be transferred to resident’s own files. Shortfalls were evident in respect to entries in resident’s daily records. Gaps were seen on a regular basis. Residents files are currently stored behind the managers desk and are not easily accessible to staff. The care plans and daily logs need to be easily available for staff to read and complete on a regular basis. Risk assessments were in place for the permanent residents covering areas such as falls, continence and wheelchairs. One risk assessment for swallowing showed a speech therapist had been involved The three-respite resident’s files did not contain care plans or risk assessments. One file showed on the log that the resident had fallen during his current stay on the 8/01/07 and the 10/01/07 and fallen on his previous stay 11/01/06. No falls risk assessment had been drawn up and no care plan was in place to show the support the resident needed. Another respite residents file held a care manager’s assessment that documented that the resident needed supervision when mobilising and was at risk of falls. This information had not been used in the homes assessment or to compile a care plan/risk assessment. Staff not having the information they need to care for respite residents means they could be putting residents at risk. The care plans in place recorded involvement of health professionals and included visits from doctors, district nurses, chiropodist and optician. The optician visited the home on the day of inspection. Weights were recorded regularly by the activity co-ordinator but these were not transferred onto resident’s files. As the activity co-ordinator is currently not at work her duties need to be given to other staff to complete. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 13 Prior to inspection comment cards were forwarded to local doctors in order to obtain their views. One comment card was returned and showed that they had no concerns about the health care standards in the home. On one file good practice was seen with a copy of a sheet introducing a key worker to the resident, this included a photograph. The sheet was also put into the resident’s bedroom if they needed it. The activity programme at the home (see life and social activities section) includes activities to keep residents active and includes armchair aerobics and music and dancing. Medication policies and procedures were in place and included the policy for residents who wished to self-administer. The area were medicines were stored was clean and tidy and kept locked. Only trained staff administered medicines and certificates confirmed that training had taken place. Most medication was supplied in a monitored dosage system (MDS) with pre-printed medication administration records (MAR). Medication appeared to be given and signed for correctly. On the day of inspection, observations showed that personal care and hygiene needs were met in a discreet and sensitive way. Staff encouraged residents to move at their own pace to the dining tables at lunchtime. A resident said when asked if staff knock on her door before entering, “some knock, some don’t I don’t really mind either way.” The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 14 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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A social activity programme is normally provided on both an individual and group basis for the enjoyment of residents however community access is limited. Visiting arrangements at the home are good ensuring links between residents and their relatives and friends are maintained. Meals are good and the needs of residents are well catered for with a well balanced and a varied selection of food on offer. EVIDENCE: The activities co-ordinator is currently absent from work for a number of weeks. She works Monday and Tuesday mornings, Wednesday afternoons and all day Thursday. A programme of activities is normally available and can include pamper mornings, sports, music, armchair aerobics, crafts and chats. Artwork produced by the residents was pinned on the corridor wall and included sheets from children’s colouring books. For the dignity of residents artwork should be displayed appropriately. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 15 The co-ordinator produces an activity sheet each week so residents know what is available. Some residents prefer not to join in the activities and said that they like watching the television, reading or looking at the newspaper. Entertainers come into the home occasionally and the home organises joint birthday parties for residents approximately every other month. During warmer weather pub lunches are organised and trips to the shops. One resident said that staff sometimes take her to the local shop to buy her chocolate. Currently because of the absence of the activities co-ordinator few activities are taking place. The manager should consider additional staffing so activities can be arranged on a regular basis. Residents said, “ there are sometimes things going on, sometimes not. I am really bored I like to be busy,” and “I’m happy enough, it’s better than being on my own. I like reading.” One member of staff said that more community activities would be beneficial for residents “shops, market or arrange ring and ride.” A hairdresser visits the home every other Monday. As some ladies hair looked unkempt it should be considered if residents would appreciate a weekly visit from the hairdresser. The home has an open visiting policy and a relative spoken with said they visited three times a week and were always made welcome. Residents can see their visitors wherever they wish in the lounge or their rooms. A visitor’s book showed the times that people had visited. Posters are displayed informing residents/relatives/friends of independent advocacy services. Communion is held for residents of the Roman Catholic faith each Sunday morning. Personal possessions of permanent residents were seen in their rooms .A resident said that she had brought all her own things with her. The choices residents made each day were varied and within their capabilities. Residents were generally free to choose what time to get up, go to bed. What clothes to wear, what to eat (within the options of the day) and whether to join in activities (when running). Mealtimes were at set times but the chef said that he will make anything anytime for the residents and it was observed that he had made individual meals for some residents on the day of inspection. The chef and residents said that at least two choices of meal were served at lunchtime and two more choices at teatime. The chef is very experienced and has stopped the rotating menus preferring to get to know the residents likes and dislikes and base the meal choices around these. He asks residents each day what they would like and keeps records of what has been cooked and on what date. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 16 The lunchtime meal was observed. Staff served the meal. Residents had chosen between ham omelette, mashed potato and vegetables or a prawn salad. One resident who did not want either was made homemade soup. The meal was freshly made and the portion size good. A hot or cold drink was available. It was observed that tea was served from a very large institutional teapot. An alternative to this should be used. Although there are no special diets required currently the chef seemed knowledgeable of the possible requirements of residents and would provide these as necessary. The chef left the hatch open when cooking and two ladies were observed arranging their chairs so they could watch the food being prepared and chatting from time to time with the staff in the kitchen. Residents were very complimentary about the food saying, “foods good,” “there’s always a choice, they make me drinks to take to bed with me,” and “there’s plenty of food, meals are good.” The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 17 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 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints policy with some evidence that residents/ relative’s complaints are listened to. Appropriate systems were in place to protect residents from abuse whilst staying/living at the Oaks. EVIDENCE: A complaints procedure was in place. The procedure was in the file displayed in the entrance to the home and was given to residents/relatives as part of the handbook residents receive when they move to the home. A system was in place for recording the concerns and complaints brought to the homes attention. The complaints file was examined to find one complaint had been documented since the last inspection. The complainant had yet to be replied to. Two concerns/complaints had been received by the CSCI. These were discussed with the manager who will investigate them following the procedure and reply to the complainants sending a copy to the CSCI. Some small complaints/grievances of residents and relatives are not documented for example a visitor said the only complaint she had was her relatives clothes regularly go to other residents. It was discussed with the The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 18 manager that these complaints should be documented to show how the home responds and takes concerns seriously. A user-friendly complaint poster displayed in reception would show both residents and relatives that the home welcomes comments and uses these to improve the service. Many compliment/thank you cards were seen in both the entrance to the home and the office. The messages showed that families had appreciated the care given to their relative. These could be dated and kept in a compliments file. The home has a protection of vulnerable adults (POVA) policy and procedure. New staff cover what is considered abusive and inappropriate behaviour as part of their induction. Staff spoken with confirmed this. The manager had a copy of the Wigan POVA policy and was arranging to order the DVD that is available from the local authority. Staff spoken to had not undertaken refresher training for some time. The manager should ensure POVA training is scheduled as part of the training plan for 2007. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 19 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, 20 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most areas of the home are safe and clean with furniture and fittings that provide comfortable surroundings for residents. However the environment does not assist residents with dementia to remain as independent as possible and the health and safety risk to residents and staff caused by the smoking lounge needs to be minimised. EVIDENCE: The Oaks is a purpose built two storey residential home with level access providing twenty-eight bedrooms (three are double rooms and are available for couples). It is situated near to Hindley and within walking distance of local amenities. Adequate parking is available at the front of the home. Garden areas are pleasant and safe providing seating areas and raised beds for residents during the summer months. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 20 In general the home was clean and odour free with the exception of the lounge/dining room carpets and chairs. The carpets in this area needed a deep clean and were badly stained and marked some chairs were in need of scouring. It was noted that the domestic was using a carpet cleaner in the upper floor corridor and bedrooms cleanliness in these areas was good. However the worn, stained chair and the ‘blown’ double-glazed unit on the landing should be replaced. The manager said that bedrooms are decorated and new carpets lay when a room becomes empty. A number of areas of the home would benefit from decoration in particular the lounge dining room area so standards do not drop below an acceptable level. Signage round the home was poor. All toilets had different signs on them. One sign was a piece of paper stuck up with sticky tape. Signage should be improved around the home to assist residents with dementia. This would enable them to remain as independent as possible for as long as possible. Consideration should be given to painting doors different colours, small memory boxes outside bedrooms and signs on toilets being a bright colour with the same clear symbol on each. Environmental health and the local fire service have both visited since the last inspection July 2006 and February 2006 respectively. A requirement made by the environmental health officer to repair the damaged kitchen floor and recover had been implemented. The communal lounge/dining area provides a light comfortable area for residents to relax in; residents who smoke use the annex to the lounge. Residents are entitled to a smoke free sitting room. On the day of inspection the smoke was drifting throughout the lounge/dining room areas. One resident said, “I don’t like the smoke” and a member of staff said, “I go home with my clothes smelling of smoke”. The smoking area needs to be moved away from the main lounge area so other residents are not put at risk. A comfortable conservatory is available for residents to use but this was not heated on the day of inspection and was very cold. Only portable heaters were seen in the conservatory; these were not switched on. No residents were using the area on the day of inspection. The laundry and storage room were sited away from the food preparation area. The laundry although small had sufficient equipment but was not clean. Floor areas in front of the machines needed cleaning, as did the handles to the tumble driers. There was an odour in the laundry. This was caused by urine soaked clothing being left on top of other residents clothing. A relative said that her mother didn’t always get the right clothes and a resident confirmed this saying that some people didn’t mind but she did “I have some nice clothes.” The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 21 Policies and procedures were in place for infection control. Equipment that was needed when assisting residents with personal care was provided for all staff. Staff said they had everything they needed. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 22 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, & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While sufficient staff work on each shift, additional staff may need to be employed to ensure the standard of care provided for residents is not compromised at busy times of day. Recruitment and selection procedures were robust and protected residents. The majority of staff were trained to do their jobs. EVIDENCE: Inspection of rotas showed that three staff were on duty on both of the day shifts and two staff on duty at night. The managers hours are used as part of the rota, which means that when she is undertaking management duties only two staff are caring for residents. It should be considered if this is sufficient to meet the needs of current permanent and respite residents. When asked if they thought enough staff were on duty staff said, “ if I’m honest no on some days,” and “I’m not sure.” Residents were very complimentary about the staff saying, “ they are kind, really good,” “ they have a chat” and “they are good girls, always busy.” The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 23 It was evident from talking with staff that they enjoyed working at the home saying, “it can be really hard, but it’s really friendly,” and “ staff and residents are great. It’s a good team, I enjoy coming.” The pre-inspection questionnaire completed by the manager showed that eleven of the twenty-one care staff currently has an NVQ (national vocational qualification) 2 in care. The remaining care staff should be encouraged to enrol for the NVQ 2 and new staff should enrol within six months of starting their employment at the home. Inspection of three staff files showed that Criminal Records Bureau (CRB) checks that the home had applied for were all in place. The manger said that she now retains all the necessary information including two written references, identification, health declaration and application form. These were seen on the two most recent staffs files. It was discussed with the manager that interview notes should be kept showing reasons for any gaps in employment. Acknowledgements were seen on two staff files saying they were aware of all policies and procedures these had been signed by staff. The file belonging to a recently recruited member of staff showed that induction was provided. Staff said that they had been shown around the home, got to know residents, shadowed experienced staff and gone through a written induction sheet. The manager needs to ensure that the induction that staff receive covers areas documented in ‘skills for care induction standards.’ Staff had not received a copy of the GSCC (general social care council) code of practice. The manager said she would obtain these and distribute them to staff. Training records were in place for all staff. These showed training had taken place since the last inspection and staff confirmed this. Training included, yesterday, today and tomorrow(dementia awareness training) administration of medication emergency first aid hearing awareness optical awareness diabetes awareness. Moving and handling refresher courses were currently being organised and a list of participant’s names was seen on the office wall. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 24 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, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager of the home has the resident’s interest at heart but needs additional support to ensure management tasks are fully undertaken. Some quality assurance systems are in place to ensure residents and other stakeholders can voice their opinions. The home has a good system for ensuring the health and safety of residents and monies are safeguarded. EVIDENCE: The registered manager has seventeen years experience in managing residential care services. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 25 The manager has an NVQ 4 in care and a registered managers award (RMA). The owner lives next door and ensures to the daily maintenance of the home. Improvement was noted in the meeting of some of the requirements identified in previous CSCI reports but a few remained outstanding. Currently the manager works twenty-nine hours and the deputy has reduced her hours; she will be absent from work in the near future. If care plans, risk assessments and other tasks are to be improved/completed and staff have the information to provide the care that residents need additional management hours will be required. The home has a quality audit system. The manager completes her own quality audit around the home. The manager said she was thinking of suggesting swapping with the manager of a sister home in order to obtain a more objective view. Satisfaction surveys are normally completed yearly. The last survey was held in 2005. The manager is planning to survey residents, their relatives and other stakeholders early in 2007. Formal residents meetings are not held but the chef meets with residents to discuss the food they want to be served, although minutes were not produced a resident confirmed that this happens. At present staff meetings are not being held. These should be arranged. A newssheet has been produced in the past by the activities co-ordinator and given to residents and their relatives informing them of what is being planned and included pictures of what has been happening at the home. This is good practice and should be continued on a regular basis and in the absence of the co-ordinator. The system for safeguarding resident’s monies was good. Families generally undertook the management of resident’s finances. Only personal allowances are held for any purchases made. Money was found to correspond to the log for the two residents that were checked. A staff supervision plan was seen and discussed. The manager said the aim was to hold six supervisions per year. The files showed that supervision was being held on a regular basis. Staff spoken with did confirm that they had received supervision and had found it helpful. One member of staff said, “I feel I can talk to Denise.” Training records showed that health and safety training was provided on an ongoing basis. No health and safety hazards (other than the smoke in the lounge) were noted during the inspection. Regular maintenance checks had been undertaken. A fire plan was in place, the fire equipment had been checked February 06 and the last fire drill held on 3/1/07. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 26 Staff said that the manager was “supportive” and “will always make note of my concerns.” A social worker who returned a comment card said, “ I have always found the manager to offer a good service to people who require complex care. She will always try to care for people before decisions to move on are made.” The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 27 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 1 X X X X X 1 STAFFING Standard No Score 27 2 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 3 The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 28 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 OP3 Regulation 14 Requirement Pre- admission assessments must be thorough and properly recorded to ensure residents needs can be met. Timescale of 02/03/06 not met. Care plans must be completed for all residents, contain details of the residents needs and state the actions necessary to meet those needs; to ensure the health and welfare of residents are met. Care plans should be written in consultation with residents or their representative. Residents weight records should be maintained and recorded on their files in order to monitor their health. Complaints received must be investigated and the complainants replied to within twenty-eight days. Signage round the home needs to be improved for residents with dementia to enable them to remain as independent as possible. The area residents smoke in DS0000005755.V315482.R01.S.doc Timescale for action 28/02/07 2. OP7 15(1)(2) 28/02/07 3. OP8 12(1) b 28/02/07 4. OP16 22(3)(4) 17/02/07 5. OP19 23 (2)(a) 28/02/07 6. The Oaks OP20 23(2)(p) 30/03/07 Page 29 Version 5.2 7. OP26 23 (2)(d) 8. OP26 23 (2)(d) needs to be separate from the main lounge so it does not pose a health risk to residents. The carpets and some furniture 28/02/07 in the lounge/dining areas should be deep cleaned for the comfort of the residents. The laundry area should be 28/02/07 cleaned and clothing sluiced before put into blue bags. 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 OP1 Good Practice Recommendations The Statement of Purpose/Service User Guide should be updated to show the numbers, qualifications and experience of the staff. They should be produced in a userfriendly format i.e. large print, photographs and symbols to ensure all residents understand the content. Personal information gathered as part of the assessment process (social interests, hobbies etc.) should be held on residents files not the co-ordinators file to ensure confidentiality. Residents daily records should be completed daily by staff to ensure up-to-date information is available. The manager should consider a weekly visit by the hairdresser to the home for residents well being. Alternative arrangements should be considered during the absence of the activities co-ordinator to allow residents a choice of what they can do during the day. A user-friendly complaints poster should be displayed in the entrance to the home giving residents/relatives the information they need in order to air any concerns and these should be documented in the complaints log. The GSCC code of practice should be given to all staff and staff sign to say they have received this. The manager should consider whether there is enough staff at duty at all times of the day to meet the current needs residents. The owner should consider if the home has sufficient DS0000005755.V315482.R01.S.doc Version 5.2 Page 30 2. OP3 3. 4. 5. 6. OP7 OP12 OP12 OP16 7. 8. 9. The Oaks OP29 OP27 OP31 10. 11. 12. OP32 OP33 OP33 management hours to ensure the safe and effective running of the home . The manager should hold staff meetings on a regular basis in order to communicate a clear sense of direction for staff and provide a forum for discussion. Residents meetings should be held and minutes taken to ensure resident’s views are heard. A survey should be carried out with residents, their relatives and other stakeholders and the results published and used to improve the service. The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 The Oaks DS0000005755.V315482.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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