Inspection on 23/10/09 for Oak Cottage

This is the latest available inspection report for this service, carried out on 23rd October 2009.

CQC found this care home to be providing an Good service.

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

Oak Cottage 26/11/08

Oak Cottage 30/11/07

Similar services:

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Oak Cottage Oak Street Merridale Wolverhampton West Midlands WV3 0AD Lead Inspector Deborah Sharman Key Unannounced Inspection 23rd October 2009 10:00 Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Oak Cottage Address Oak Street Merridale Wolverhampton West Midlands WV3 0AD 01902 681235 01902 655793 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) Osei Minkah Care Limited Mrs Karimah Francis Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of care only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Learning disability (LD) 3 Mental disorder, excluding learning disability or dementia (MD) 3 The maximum number of service users to be accommodated is: 3 2. Date of last inspection 30th April 2009 Brief Description of the Service: Oak Cottage is a back to back semi detached house in a residential area of Wolverhampton within a ten minute drive of the City Centre. The service is currently registered to accept 3 service users whose primary needs are learning disability and or mental ill health. The service intends to admit people who have a dual diagnosis of learning disability and mental ill health: younger adults who are cognitively impaired and presenting behavioural challenges. The property is domestic in style and is comfortably furnished in a light and modern style. There is a lounge and a conservatory that offers alternative seating. There is a small patio to the rear of the property and plenty of parking spaces for cars at the front. All 3 bedrooms, which are on the first floor, are single occupancy and have a washbasin and lockable facilities. There are two bathrooms for shared use and a separate laundry. The aim of the service is to provide person centred care in a warm, safe and enabling environment ensuring that service users have optimum control over their lives. Information relating to fees is not currently contained within information about the service and should be sought directly from the manager. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for this service is 2 star. This means the people who use this service experience good quality outcomes. One Inspector carried out this unannounced key inspection on 23 October 2009 from 10.00am to 5.45pm. No one knew we were going and were therefore unable to prepare. As it was a key inspection the plan was to assess all National Minimum Standards defined by us as key. These are the National Standards which significantly affect the experiences of care for people living at the home. Information about the performance of the home was sought and collated in a number of ways. Prior to inspection we were provided with written information and data about the home in an annual return which is called an AQAA. We didn’t send surveys to the service as it is a small home and as such it is possible to talk to people about their experiences during the inspection day. During the course of the inspection we used a variety of methods to make a judgement about how service users are cared for. The registered manager and new deputy manager were available to answer questions and support the inspection process. We also talked to both of the people who live at Oak Cottage. We had the opportunity too, to talk to a visiting relative as well as to staff on duty. We looked at how both people are supported in detail using care documentation and by talking to them. We read a variety of other documentation related to the management of the care home such as training, accidents and complaints. We did not assess how new staff are recruited. This is because there have not been any new staff appointed since we last inspected this in the random inspection in August 2009. In August, other than some administration weaknesses, we were assured that recruitment practices were better protecting people. We toured the communal parts of the premises and we also went into people’s bedrooms to see how the environment meets the needs of the people living there. All this information helped to determine a judgement about the quality of care the home provides. What the service does well: Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 6 The people who live at oak cottage are happy to do so. They told us that they like it and that everything’s good. They have enjoyed two holidays this year, in Spain and in Wales and they are supported to pursue their own activities and interests. One person for example goes for walks and to the gym, while the other is supported to attend Wolverhampton Wanderers football matches, rock concerts and does work experience. A relative we spoke to told us that the staff are really nice, look after her son well and make her very welcome when she visits. She said she is pleased with how often her son goes out, feels the staff know him well and said that the home is 100 excellent. The premises are modern, light and clean and provide suitable, warm and homely accommodation. Medication systems are excellently managed. Records are robust and demonstrate that people are receiving their medication safely and as prescribed. This standard of practice supports people to maintain and improve their physical and mental health. What has improved since the last inspection? Since the last key inspection in April 2009, we carried out a focused random inspection in August 2009 and were satisfied that sufficient progress was being made to ensure peoples health and safety. Since then further progress has been made in a short time and we consider, that the home is now providing a good rather than a poor quality service. We consider that all requirements and recommendations issued at previous inspections have now been sufficiently met and have been deleted. Contracts have been provided so people better understand their rights and responsibilities and information about how to complain is readily available to people. In particular, there is now good evidence that people are being supported to attend all their health appointments and steps have been taken to identify and minimise risks from arson, hazardous chemicals and hot water. Outcomes are being better supported by the provision of improved care plans, which are being updated when people’s needs change. This means that staff are being provided with better guidance about what is expected of them. Consequently records of care are more detailed and accurate. This provides effective evidence of good practice and also supports the service to monitor and evaluate peoples care and well-being. Since the last inspection, the registered manager has appointed a deputy manager for the first time and she has improved systems and is providing effective direction, support and leadership to the staff group. Practice is now being better monitored with improved outcomes for the people who live there. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 8 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 5. People using the service experience adequate quality outcomes in this area. People who live at the home have now been issued with contracts to help them to understand their rights and responsibilities while living there. Other documentation however is not up-to-date and therefore does not provide accurate information for either them or any one who might consider moving into the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: No one new has moved in since we last inspected so we were not able to assess steps taken by the home to assess and support prospective residents. Brochures which should be given to prospective residents need to be up dated as we could see our address is inaccurate and the weekly fee is not in the information. We also could not be assured that this information has been provided to existing residents in appropriate and understandable formats. Managers agreed to address this. However, it is positive that since the last Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 11 inspection, residents have been issued with contracts to explain their rights and responsibilities. Steps need to be taken to ensure that people understand the information they were given as surveys carried out by Oak Cottage suggest this not to be the case for one of the two people living there. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. People using the service experience good quality outcomes in this area. People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent because the staff have appropriate information on which to base decisions. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Care plans have been reformatted and provide clear guidance for staff about how they should provide people’s care. People’s cultural needs i.e. skin and Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 13 dietary care are met but to ensure that this is clear to all current and future staff, we agreed that the support required needs to be described in care plans. Risk assessments are also in place and consider risks pertinent to each person and explain how these risks should be reduced. It is positive that people have been involved in agreeing these and that when people’s needs change, the guidance is updated, ensuring that staff have accurate information available to them. We could see that staff have also received guidance and direction about how to meet needs and risks in staff meetings. Both people who live at Oak Cottage and a relative told us they are happy with how they are supported and feel their needs are understood and met. We can also see that the home is working proactively with the purchasers of their service to try to arrange multi agency reviews of the care provided. People are happy that their wishes and choices are respected. We observed respectful interaction between staff and the people who live there. Care records describe choices people have made and how staff have facilitated these such as visits to the pub, swimming, cinema. We were also able to see that where people change their mind about things, that staff understand and respect their right to do so. Where limitations are imposed, for safety reasons, these are explained and agreed in written assessments of risk. For example, smoking tools are handed in to staff at night and returned in the morning to reduce the risk of fire. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 14, 15, 16, 17. People using the service experience excellent quality outcomes in this area. Each person is treated as an individual. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have healthy, well-presented meals and snacks, at a time and place to suit them. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: How the home supports people with activities is a particular strength of the service. The home is small, staff know the people who live there well and are Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 15 able to provide individualised activities of choice. One person for example has a work experience placement, goes to football matches at Wolves and goes to rock concerts. He is also supported to attend other community events which interest him, such as community drama sessions and he went to a rock and roll dance where with staff help, he met up with his parents and people whom he hadn’t seen for many years. He was preparing to go to a rock concert during the evening of the day we inspected. He was supported by a staff member who arrived at work dressed appropriately ‘to rock’ to the amusement of the residents and staff. At a residents meeting, staff asked how activities could be improved. One person would like to enrol at college and having had two holidays this year, in Spain and Wales a further aspiration of his, which staff are aware of is to go to America to see Elvis Presley’s House. The other person told us he is happy with how he spends his time. He attends a cultural day centre, goes to the gym, was supported to attend a community Black History event and also enjoyed two holidays. He pointed out the X Box that the home had recently purchased for the two residents to share. From looking at records we could see that people also regularly go swimming, to the cinema, to bowling and to local pubs to play pool and karaoke. A resident had told staff that he would like to resume grocery shopping and he told us that he now does this. People said they enjoy their meals and they are able to have a variety of foods including culturally appropriate meals. We saw one person being encouraged to prepare his own sandwiches to promote his life and independence skills. People told us that they are able to have alternative meals if they do not like what is planned. Meals taken are now being recorded to help the evidencing and monitoring of food intake. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. People using the service experience good quality outcomes in this area. People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. The care home supports people with medication in a safe way that ensures they receive their medication as prescribed. This promotes people’s health and helps to keep them well. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We spoke to one person who said he can have a bath or a shower whenever he wants to and that there is always plenty of hot water. We could see that staff are regularly checking the temperature of the hot water to ensure it complies Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 17 with the safe range to avoid the risk of burns and scalds. People present as clean and well groomed and are supported to buy their own toiletries and clothes to reflect their personal style and age. Health records are much improved and demonstrate that people are being supported to attend routine and specialist medical appointments. One person has monthly blood tests. We have suggested that these are recorded in the same way as all other appointments on a specific and separate form as we found the two blood test appointments recorded in different places. We followed up a health appointment which had been overlooked at the last inspection and could see that this has since taken place along with treatment on two subsequent occasions. We could also see that where since the last inspection, someone’s health had changed, the GP was consulted whose advice and treatment were followed. A relative we spoke to is very satisfied with how health is managed and commented on the health improvement she had noticed in her son. We looked very closely at how medication is managed. We audited a number of different medications and using the robust records available to us along with counting medications on the premises we could see that the system is being managed extremely accountably. People are receiving their medication as it is prescribed. This will promote people’s physical and mental well being. Congratulations are due to the staff member who has accepted lead responsibility for managing and improving medication management from initially poor to what we now consider to be excellent practice. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. People using the service experience good quality outcomes in this area. If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection, we can see that information about how to make a complaint is now publicly available within the premises in both an easy read and more detailed format. There have not been any complaints about the service and we can see that people feel able to give the service feedback, so matters can be addressed before they become complaints. A visiting relative told us they have no concerns about the quality or safety of the service and have not had to complain. There have been two safeguarding incidents, neither of which implicated staff or fellow residents. However, where staff failed to act appropriately, action was immediately taken to address this. Managers reported the incidents Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 19 immediately to Social Services, the lead safeguarding agency. There is some debate about how the information provided was initially responded to by Social Services and to avoid this in future both the registered manager and deputy manager have been strongly advised to submit any safeguarding referral on appropriate paper work. This will avoid the potential for communication breakdown and will provide documentary evidence of action taken by them to report allegations. In the meantime we are assured by Oak Cottage that a safeguarding plan is in place and that the matters will not be subject to further investigation by the local authority or the Police. We looked at both people’s financial records and can see that systems are in place to safeguard people’s financial interests. Records are detailed, receipts are retained and people whose money it is, countersign with staff to agree their expenditure. One person who is able to takes additional responsibility for managing his own money. He is given a daily allowance that he manages himself without having to account for it with receipts etc. This promotes his independence and self respect. Written guidance is available to staff about how to manage behaviours that challenge and this has been reinforced in a staff meeting. There have not been any significant behaviour incidents and perusal of records show low level behaviours that staff have de escalated well. Behaviour management training has not been provided since we last inspected but training has been booked for all staff who need it and will be completed between October 2009 and January 2010. Most staff have received training in abuse, protection and safeguarding matters. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. People using the service experience good quality outcomes in this area. People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The premises continue to provide accommodation to the same standard since the service was first registered as a care home. The layout, fixtures and fittings are warm, comfortable and homely. One person showed me his bedroom and he was very pleased with recent improvements to it. He has had newly fitted cupboards, new tiling around the basin and a wall mounted new Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 21 flat screen television. We were told that they are considering converting an unused spare downstairs room into a games area for the additional benefit and enjoyment of the people living there. When we looked around we found everything to be very clean, fresh and tidy. A new cleaning rota is in place and is being closely monitored by managers. There were no evident hazards. We found a cupboard used to store chemicals locked, as was the laundry, where hot water could be a hazard. Water temperatures are being regularly checked. One particularly low ground floor window is not restricted and we have advised the managers to risk assess this in relation to intruder risk. We suggest they also speak to the Fire Service as they expressed concern about exit in the event of a fire should the window be restricted. Information obtained can then inform the formal risk assessment. The laundry is well ordered and clean. Protective equipment is available but we have suggested that paper towels will be easier to use in the laundry if a dispenser is fitted to the wall. Currently paper towels are stored in the laundry cupboard. The deputy manager has recently attended an Infection control workshop which she found useful and intends to share some learning materials provided, with staff at the next staff meeting. Completed satisfaction questionnaires developed by the home show us that both people who live at Oak Cottage are satisfied with the accommodation available to them. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 24, 35, 36. People using the service experience adequate quality outcomes in this area. People are supported by a developing and improving staff team. Staff have not yet received all the training and supervision they need, but a robust plan is in place and we can see that action is being taken to provide this. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A visiting relative spoke highly of the staff, describing them as ‘really nice’. She said they know her son well, look after him and communicate well with her. She was pleased to tell us that staff had told her that her son is their priority. One person living there talked about staff being ‘good’, ‘fine’ and ‘nice people’. We observed staff to be respectful, co operative and keen to accept feedback to ensure the service improves. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 23 Staff have been able to demonstrate at this inspection greater accountability for their practice. Written care records for example are hugely improved, detailed and accurate, showing monitoring and evaluation of the activities, support and care they provide. They are gaining confidence as individuals and as a team. The manager explained that they are fully staffed and no new staff have been recruited since we last inspected. In preparation for when any new staff are appointed the managers are aware of the need to review how they are inducting new staff to ensure that induction standards comply with current standards. Most staff have either done or are doing national vocational qualifications and a new training programme shows they have been booked onto a range of courses considered necessary to prepare them for their job roles between now and early in the new year. These courses include Equality and Diversity, Managing Challenging Behaviour, Moving and Handling and Medication training for those who still need to do this. Given the needs of the people living at Oak Cottage it is positive that most staff have had training about the Mental Capacity Act, but now need additional training covering Deprivation of Liberty. Staff have not received a minimum of six formal recorded supervision sessions with their manager in the last 12 months but since the appointment of a deputy manager in July 2009, this is beginning to improve. The deputy manager is booked to attend a course about staff supervision but records that we saw, demonstrated the content of supervision meetings to be full and satisfactory. We looked at the rota and could see that arrangements for staff cover are clear and accountable. From looking at the rota we could see who was covering the night shift and who was available on call to give staff out of hours support. The rota showed generally one person is on duty in the mornings and two in the afternoons and evenings. However, when we arrived in the morning we found two staff members on duty and additional staff are provided as required to support special activities, such as the rock concert which one person had tickets to attend on the evening we visited. Three staff, supporting two people were planning to attend a planned day trip to Blackpool the week after inspection. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. People using the service experience good quality outcomes in this area. People get the right support from the care home because new management arrangements are ensuring it runs appropriately. People are safeguarded because the home keeps records appropriately and makes sure staff understand the way things should be done. The environment is safe for people and staff because health and safety practices are carried out. We have made this judgement using a range of evidence, including a visit to this service. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 25 EVIDENCE: The registered manager has appointed a deputy manager since the last key inspection and this has positively influenced how the service is being managed. Communication and systems have improved and we can see that staff are being provided with direction and leadership. We found that the deputy manager is managing the service on a day to day basis and because of this we have agreed, that she will apply for registration with us before the end of November 2009. The registered manager is not receiving formal supervision although she tells us she receives peer support. The new deputy manager reported feeling supported but has not received sufficient formal and recorded supervision since taking up post. In spite of this, the management of the home has improved and a relative we spoke to confirmed this. The people living there both told us that they like both managers. Steps have also been taken to implement quality assurance systems based on feedback from the people living there. On the whole people’s responses show a good level of satisfaction with the service they receive. The next stage is for the service to demonstrate what action they have taken to act on feedback where the need for improvement is identified. We followed up records of property maintenance that could not previously be demonstrated to us. On this occasion service maintenance records were available to us showing records to be better organised and that steps had been taken to maintain facilities and equipment. Progress has been made to improve systems that help to manage risk. Hazardous chemicals have always been stored safely, but written assessments posed by each substance have now been carried out too complying with the law. A range of environmental risks have also been considered and controls have been put in place. We have advised the assessor, to consider and record the levels of risks posed, as this will help them to measure to what extent the controls agreed have successfully reduced the identified hazards. Although a certificate was not available, the person who carried out the risk assessments confirmed having received risk assessment training in previous employment. The AQAA told us that there have been two admissions to Accident and Emergency hospital departments in the last 12 months. We followed this up at inspection and the registered manager confirmed this to be a recording error. There have been two admissions to Accident and Emergency in total since people moved in and not in the last 12 months. There have not been any accidents in the last 12 months. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 26 The movements of people who live at Oak Cottage are not restricted. They can come and go as they please with and without staff support depending on their abilities. The home needs now to develop, in response to new legislation introduced in April 2009, a policy about the deprivation of liberty and needs to arrange training about it for managers and staff. We now consider all previous requirements and recommendations for improvement to have been met and as such, they have been deleted. No new requirements have been made. Seven good practice recommendations arising from this inspection have been included in this report. The provision of healthcare and how this is evidenced and evaluated has improved. This, in conjunction with good levels of satisfaction from the people who live there, excellent lifestyle opportunities, prompt responses to safeguarding incidents and excellently managed medication assure us that Oak Cottage is now providing and evidencing good quality care for the people who live there. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 X 2 X 3 X X 3 X Version 5.3 Page 28 Oak Cottage DS0000070082.V378336.R01.S.doc 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. Standard Regulation Requirement Timescale for action 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 YA23 Good Practice Recommendations The service should always complete and submit an SA1 form (keeping a copy) to the local authority when reporting a possible safeguarding allegation. This will promote good inter agency communication so that safeguarding incidents are responded to appropriately and will provide the home with evidence of having reported any safeguarding matter in line with agreed procedures. Recommendation arising from this inspection October 2009. 2 YA24 Risk assessments based on advice from The Fire Service and Environmental Health Departments should be carried out in respect of unrestricted windows where there is a risk of entry by intruders or other risks to people living at the home. Recommendation arising from this inspection October Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 29 2009. 3 YA36 Ensure all staff including the deputy manager receive a minimum of six recorded supervisions in any 12 months period to ensure they receive sufficient support to carry out their job role and to ensure they are sufficiently accountable for their performance. Recommendation arising from this inspection October 2009. 4 YA37 Take steps to ensure that the service is not managed on a day to day basis by someone not registered to do so. It was agreed at inspection that an application for a new registered manager would be submitted to CQC by November 30 2010. Recommendation arising from this inspection October 2009. 5 YA39 Take action to address areas of weakness identified by people in quality assurance feedback surveys / questionnaires. This will ensure the service improves in ways that are important to the people who live there. Provide evidence of what has been done to ensure feedback has been addressed. Recommendation arising from this inspection October 2009. 6 YA40 Steps should be taken to develop a policy about Deprivation of Liberty in response to new legislation. Managers and staff should receive training about this legislation and policy. Recommendation arising from this inspection October 2009. 7 YA41 It is suggested that blood monitoring tests are recorded on a separate health appointments form so these can be seen and monitored at a glance. Recommendation arising from this inspection October 2009. 8 YA42 It is suggested that when carrying out environmental risk assessments that the level of risk is determined and DS0000070082.V378336.R01.S.doc Version 5.3 Page 30 Oak Cottage recorded to demonstrate whether controls agreed are effective in reducing the risk of the hazard identified. Recommendation arising from this inspection October 2009. Oak Cottage DS0000070082.V378336.R01.S.doc Version 5.3 Page 31 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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