Inspection on 16/01/06 for 15 Oaklands Road

This inspection was carried out on 16th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

15 Oaklands Road 20/05/08

15 Oaklands Road 14/06/06

15 Oaklands Road 11/10/05

15 Oaklands Road 25/01/05

15 Oaklands Road 17/08/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 15 Oaklands Road 15 Oaklands Road Bedford Bedfordshire MK40 3AG Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 16th January 2006 01:15 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 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 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 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 Adults 18-65. 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. 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 15 Oaklands Road Address 15 Oaklands Road Bedford Bedfordshire MK40 3AG 01234 347822 01234 352427 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) Community Care Solutions Limited Care Home 7 Category(ies) of Learning disability (7), Physical disability (7) registration, with number of places 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One resident may have an additional physical disability The manager must complete an NVQ 4 in care and registered manager`s award by 31 August 2006. 11th October 2005 Date of last inspection Brief Description of the Service: Oakland’s is a detached house situated in a residential area of Bedford owned by Community Care Solutions Ltd. The home is approximately one mile from Bedford town centre and is close to a bus route into the town. There is a shop/post office close to the home and pubs and places of worship nearby. The accommodation is on two storeys, with two bedrooms, shower room, lounge, kitchen/diner, activity room and conservatory on the ground floor. There are a further five bedrooms and a bathroom and shower room on the first floor. The home has an attractive garden to the rear. The home is registered for 7 adults with learning disabilities. 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection that took place at 01.15pm on 16th January 2006 and lasted over 3 ½ hours by PursotamRaj Hirekar. The inspection methodology included study of three service users files, conversation with service users, discussion with the manager and staff on duty, study of various relevant documents and tour of the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 6 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 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 The home must ensure that the care plans and risk assessment must entail greater detail of information taking into account the findings from the reviews to ensure that the service users changing needs are not overlooked. EVIDENCE: Three service users care plans and risk assessment were examined. The risk assessment and the care plans were documented in November 2005. The risk assessments and the care plans had details including information on accommodation, personal care, medication, medical needs, domestic tasks, communication, freedom of choice, protection, health, family, counselling, faith, finances and transport. The manager, key worker and the service user signed the care plans. However, the care plans were not reviewed since 17.11.2004 and were scheduled for February 2006. Care plans must take into account the changing needs of service users through regular care plan review. The manager had said that the care plans review is scheduled in February 2006 and agreed to revisit the care plans basing on the findings from the review and incorporate changes as required before the end of February 2006. 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 17 The home had made appropriate arrangements to engage service users in various activities and mainstream them into the larger community. EVIDENCE: The home had made appropriate arrangements for day care and leisure activities which include personal care, medication, college, in-house activities, walk, room cleaning, sports, swimming, and drive out. The food supplies were inspected on this inspection and found that the food stock was adequate and the kitchen was clean. The dinner menu was prepared in consultations with the service users. The service users’ spoken to have expressed their satisfaction with the day care activities and choice of food. The staffs on duty engaged service users during their leisure time in stimulating activities that help them develop their personalities. 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 In the absence of regular health care needs review, the service users’ health care needs may be over looked. EVIDENCE: The service users’ spoken to have said that they have received personal support from the staff on duty to meet personal needs as and when they required. The medical records of service users inspected were found up to date and were documented systematically. However, there was no evidence of health needs of the service users’ were regularly reviewed. The senior staffs of the home administer medication to the service users. 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home had made appropriate arrangements for the protection of service users. EVIDENCE: The home had made changes to the name from National Care Standards Commission (NCSC) to Commission for Social Care Inspection (CSCI) in their complaints procedure document. There was no evidence at the home that the POVA policy was reviewed in light of the previous inspection report requirement. However, the manager had said that the work was in progress at the head office and would be completed by the end of February 2006. The staff training files recorded that except for one staff that POVA training was scheduled for 26.01.06 all other senior staffs have received POVA training. The manager confirmed this during the feedback session. 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 30 The home had taken appropriate measures to redecorate the premises to ensure comfortable environment for service users. EVIDENCE: The home had taken appropriate measures to replace blinds, carpets and curtains. The manager had said that this work would be completed by mid February 2006. Service users bedrooms, bath, lounge and the kitchen were clean and tidy. The bedrooms and bathrooms provided sufficient ventilation and were decorated to suit the choices and tastes of service users. 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 In the absence of complete documentation of staff profiles and regular review of risk assessment and care plans the home leaves the service users’ vulnerable to harm and abuse. EVIDENCE: The manager had attempted to organise relevant staff details with regard to their pre-employment checks and training. However, there was no evidence of POVA checks. The individual staff files did not have evidence to support their qualification and experience prior to their working at the home. The manager had agreed to organise the relevant information and keep at the home before 10/02/06. On the training front, it was evident from the staff training files that the stafftraining calendar detailed information of staff training programmes and their participation. It was difficult to establish, service users’ individual and joint needs were met appropriately in the absence of regular reviews of risk assessment and care plans. 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The home must ensure to invite and enlist service users’ and their representatives’ views and suggestions to improve the services of the home. EVIDENCE: The manager had submitted an application for registered manager with CSCI. The manager had taken measures to meet some of the requirements from the previous inspection report. However, the manager needed to speedup without compromising on the quality. The manager said that the head office is working on the quality assurance system and audit and the work would be completed before 1st week of February 2006. However, there was no evidence to this effect at the home. The home had made arrangement for the safety and welfare of the service users’ by way of ensuring regular checks and repairs of fire safety, electrical appliances, gas, and hot and cold-water temperatures. 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 15 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 2 x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 2 x 2 2 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 15 Oaklands Road Score 3 2 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 3 x DS0000014940.V272263.R01.S.doc Version 5.0 Page 16 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 YA6 Regulation 15 Requirement The registered person must ensure that service user’s care needs; reviews and areas of risk are recorded in sufficient detail. Care plans must show evidence of consultation with service users. (Previous time scale 11/01/06 partially met) Timescale for action 25/02/06 2. YA8 13(4)(c),14 The registered person must ensure that risk assessments are reviewed regularly. [Previous timescale of 30/4/05, 11/12/05 not met.] 12(1)(a)(b) The registered person must ensure that the health care needs of service users are regularly reviewed and appropriately met. (Previous time scales 11/01/06) 13(6) The registered person must ensure that the homes adult protection policy is reviewed in accordance with local authority procedures. (Previous time scales 11/01/06) 25/02/06 3. YA19 25/02/06 4. YA23 25/02/06 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 17 5. YA34 19 Schedule 2 and 4 The registered person must 10/02/06 ensure that information is maintained in the home on each member of staff as detailed under schedule 4 of the Care Homes Regulations 2001. [Previous timescales of 30/9/04, 31/3/05 and 11/01/06 not met.] The registered person must ensure that a quality assurance system is implemented. This must seek the views of service users, their relatives and other professionals. A report of the findings and any recommendations must be compiled. (Previous time scales 11/01/06) 10/02/06 6. YA39 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 15 Oaklands Road DS0000014940.V272263.R01.S.doc Version 5.0 Page 19 - 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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