Oakdale Manor
Rhiw Syr Dafydd Road, Oakdale, Blackwood, NP12 0JJ.
Tel: 01495 230900
Email: oakdalemanor@btconnect.com
Contract Monitoring Report
Name/Address of Provider: Oakdale Manor Residential Home
Date/Time of Visit: 6 & 12 September 2023
Visiting Officer(s): Ceri Williams, Contract Monitoring Officer
Present: Amanda Edwards, Registered Manager
Background
Oakdale Manor is registered to provide dementia residential care for up to 31 people the home is split over 2 floors. At the time of the visit there were 21 residents living in the home.
Dependant on the findings within the report, corrective and developmental actions may be given to the provider to complete. Corrective actions are those which must be completed as governed by regulations such as the Regulation and Inspection of Social Care Act (RISCA), and developmental actions are good practice recommendations.
Previous Corrective / Development Actions
Corrective
The Personal Plan is kept under review and is amended and developed to reflect changes in the individuals care and support needs. Regulation and Inspection of Social Care (Wales) Act 2016 (RISCA) Regulation 16.
Met: Personal Plans viewed evidenced plans are reviewed and amended when necessary.
The service provider to ensure all staff receive appropriate core and refresher training. RISCA Regulation 36.
Met: All staff were up to date with mandatory training with only some overdue refresher courses which have been booked.
All staff to receive appropriate supervision and appraisal within timescales set out in legislation. RISCA Regulation 36.
Not met: See body of report.
A record of all persons working at the service must include a copy of the persons birth certificate and passport (if any). RISCA Regulation 59 Schedule 2, Part 1 8 (b).
Met: A sample of staff files viewed at the visit contained a copy of a birth certificate or passport.
The service to be compliant with recommendations made by South Wales Fire & Rescue Service. RISCA Regulation 57.
Met: Evidence was provided that concluded all recommendations had been completed.
Fire evacuation and drills to be carried out regularly and documented. RISCA Regulation 57.
Met: Evidence was provided of fire drills being carried out and recorded.
The Responsible Individual to visit the service at least every three months and document the visit. RISCA Regulation 73.
Partly Met: See body of report.
The Responsible Individual to produce a Quality of Care Report with sufficient detail as required by legislation. RISCA Regulation 80.
Met: Upon clarification from the regulator it has been confirmed that the home are not required to complete these reports.
Safeguarding Policy to reviewed and updated to ensure alignment with current legislation, national guidance, and local adult safeguarding procedures. RISCA Regulation 27.
Met: The policy has been updated.
Developmental
Formalisation of risk management/assessment process following disclosure on DBS Certificate.
Met: Evidence was provided of a documented risk assessment now in place if required.
Policies and Procedures to be dated to evidence that they are being reviewed in a timely manner.
Met: Document available to evidence that policies are being reviewed in a timely manner.
Findings
Documentation
Personal Plans reviewed at the visit were detailed and included all the care and support needs identified by the CCBC care and support plan. The plan format has been specifically designed for dementia care. Plans were written from the individuals perspective of what support they required and what could be achieved independently and included preferences and routines. Individuals outcomes in each area of the personal plan were also specified.
The personal plans contained information about likes and dislikes and gave prompts to staff around what the residents like talking about and doing, and what subjects or activities to avoid. The prompts in the documentation include ‘what I can do for myself’, ‘what I find difficult’, ‘areas of risk for me’ and ‘what you need to do to keep me safe’.
Personal plans viewed did not include signatures from individuals or their representatives to evidence that they had been involved in the compilation of the plans. However, there was a booklet on file used by the home called ‘This is Me’ developed by the Alzheimers Society. These had been thoroughly completed with the individual and support from their relative or representative, giving a good insight of the individuals care & support needs and their well-being.
Files viewed contained relevant risk assessments for identified areas of risk and provided guidance to manage risk. Risk Assessments were also reviewed within necessary time frames.
Personal Plan reviews are carried out bi-monthly. Reviews are detailed and meaningful and include if there have been any incidents since the last review and any changes to Personal Plans.
Daily records viewed were consistent with the care and support needs in the Personal Plan and included details of medications administered, personal care, food and fluid intake, mobility, activities and general presentation.
Evidence was available on files that the home regularly engages with, and refers to, appropriate outside agencies when necessary to support residents including GP, CPN, Falls Team.
There was evidence available on file that individuals are assessed appropriately with regard to Deprivation of Liberty Safeguards and a process in place for review of these assessments when required.
Training & Supervision
A training matrix was provided which evidenced that staff attend regular training and refresher courses to support them to fulfil their role. Some gaps were identified in the training matrix where staff had not completed refresher training in mandatory courses, however it is acknowledged that training is ongoing with a training schedule organised throughout the year. Staff also attend some non-mandatory training courses deemed appropriate to their role.
The home uses a mixture of face to face training with an accredited provider, online training and also accesses training courses provided by Caerphilly County Borough Council. A training schedule is planned throughout the year for mandatory refresher courses. Staff can also identify their own training needs through supervision sessions.
Most staff had completed QCF level 2 qualifications with a number of staff also qualified to levels 3 and 5. The manager advised that any new employees who are not QCF qualified are enrolled and start this qualification immediately in line with the All Wales Induction Framework.
Supervision sessions with staff were seen and evidenced that these were taking place however, not within the timescales set out in legislation. Some staff were overdue supervision at the time of the visit. Supervision sessions are meaningful and give staff the opportunity to reflect on their practice and identify any training needs.
Staff also receive annual appraisals providing feedback on their performance and identify areas for training and development in order to support them in their role. Some staff were overdue an annual appraisal at the time of the visit.
Staffing
Staffing levels at the home at the time of the visit were as follows;
Morning: 3 care assistants and 1 senior care assistant, with an additional care assistant 8am – 11am.
Afternoon: 3 care assistance and 1 senior care assistant, with an additional care assistant 5pm – 11pm.
Night: 2 care assistants and 1 senior care assistant.
The home also employs an activities co-ordinator 24 hours per week.
In addition to the above, during the day, the home is also staffed by the Manager, Deputy Manager, Administrative Assistant, Handyman, Domestic assistant, Laundry Assistant, Cook and Kitchen Assistant.
The home do not regularly use agency staff and are able to cover absences from within the existing staff team.
Two staff files were seen during the visit. It was apparent the appropriate recruitment checks had taken place; both files contained at least 2 references from previous employers, a full application form, interview records, signed copies of contracts of employment and evidence of DBS checks. Both staff files viewed contained the necessary identification documents required.
Facilities & Observations
The home is large and spacious with several communal areas that individuals can frequent as they wish. Individual rooms were clean, well equipped and residents personal items displayed such as photographs, ornaments and comfort items.
The home was clean throughout and there were no malodours Improvements had been carried out to the outside areas of the home including clearing of paths, painting and new garden furniture which a few of the residents were observed enjoying at the time of the visit. A discussion was held with the manager regarding redecoration of some areas of the home and it was explained that the Handyman has a full programme of decoration planned in the upcoming months.
During the day there were many positive and caring interactions seen between staff and residents, and it was clear that staff make efforts to encourage a relaxed and friendly atmosphere. Staff were seen taking time speaking with residents, either walking with them or sitting with them, and promoting choice and autonomy.
Health & Safety
There are a range of weekly, monthly and quarterly maintenance checks that are completed within the home, such as legionella checks, water temperature checks, servicing of the hoists and slings, PAT testing and fire safety checks.
The Manager also undertakes various audits monthly and quarterly, including an accident and incident audit, medication audit, resident’s weight audit, and infection control audit. Audits viewed were detailed and are used to identify trends and evidenced any actions that need to be taken to reduce risk of re-occurrence.
A fire safety inspection carried out by South Wales Fire and Rescue Service identified several recommendations to reduce risk in the event of a fire. The manager was able to evidence that all the recommendations had been completed.
Fire Drills had also been carried out within the home and are recorded, including who attended the fire drill and the time taken to complete evacuation.
Individuals living at the home all had Personal Emergency Evacuation Plans. These were detailed and included clear actions for staff in the event of an evacuation and are reviewed monthly.
Quality Assurance
The Responsible Individual (RI) regularly visits the home and has good oversight of the service. Quarterly reports to monitor the service are carried out by the RI, within timescales set in regulations however, these visits did not include feedback from residents or staff as required in regulations.
A six month quality of care review, to assess and monitor quality of care and safety of the service, is not carried out by the RI, after confirmation by the regulator, that this is not required due to the service provider being an individual. However, it is still a requirement for at least an annual quality assurance report to be completed under the CCBC contract. It is also stated in the home’s statement of purpose that feedback is requested annually from stakeholders, however there was no evidence of such feedback being sought this year.
Staff meetings are held regularly with the staff team but not within the timescales set out in regulations. Meetings are recorded and minutes were available when requested. The staff meetings cover a range of subjects such as the general running of the home, infection control, staff conduct and results of any audits undertaken are also shared with staff.
A staff handover meeting takes place at the change of every shift which is lead by senior care staff. All residents are discussed and information shared is documented.
Any accidents that occur are documented on accident report forms and are reported directly to the manager who will review and advise on any actions if necessary. Accident audits are carried out monthly to identify any trends or patterns. Accidents or incidents are discussed in handover, staff meetings and supervision.
Residents are consulted as much as possible, on the running of the home, but this is done less formally and by way of conversations with residents and representatives rather than formal residents meetings.
There is a suitable complaints policy in place at the home. One complaint had been received by the manager since the last annual monitoring visit. This had been resolved and recorded appropriately. There were no safeguarding enquiries ongoing at the time of the monitoring visit.
Feedback from Relatives
The monitoring officer spoke to two relatives of individuals living at the home for feedback. Both spoke positively of the atmosphere at the home and the quality of care and support provided to their relative.
They described staff as caring and accommodating, communication with them excellent and they are always informed of any changes to their relative’s well-being.
Neither of the relatives had ever had to raise any concerns or complaints with the home but advised that they would feel comfortable to raise any issues with staff should the need arise.
Corrective Actions
Staff meet for one to one supervision with their line manager or equivalent officer, or a more senior member of staff, no less than quarterly.
Regulation & Inspection of Social Care (Wales) Act 2016 (RISCA) Regulation 36
All staff have an annual appraisal which provides feedback on their performance and identifies areas for training and development in order to support them in their role.
RISCA Reg. 36
The provider to produce an annual Quality Assurance development plan including feedback from residents and stakeholders.
CCBC Contract 24 (24.1)
Regular staff meetings take place (a minimum of six meetings per year).
RISCA Reg 38
Quarterly Reports completed by the RI to include feedback from residents and staff.
RISCA Reg 73
Developmental Actions
There are no developmental actions following the visit to the home.
Conclusion
This was a positive monitoring visit to Oakdale Manor with most of the actions identified from the last monitoring visit achieved. Individuals care & support and well-being are clearly the service providers priority, and this was evident from time spent at the home. There was a very relaxed and calm atmosphere at the home with lots of staff interaction, kindness, laughing, and re-assurance being provided to individuals who live there.
The contract monitoring officer would like to thank staff and residents for their hospitality during the visit.
Author: Ceri Williams
Designation: Contract Monitoring
Officer Date: 17/11/23