Inspection on 20/05/08 for 15 Oaklands Road

This inspection was carried out on 20th May 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

15 Oaklands Road 14/06/06

15 Oaklands Road 16/01/06

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

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 15 Oaklands Road Bedford Bedfordshire MK40 3AG Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 20th May 2008 12:45 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 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.V364260.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 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.V364260.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 15 Oaklands Road Address Bedford Bedfordshire MK40 3AG 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) 01234 347822 01234 352427 oaklands.manager@communitycaresolutions.co m www.communitycaresolutions.com Community Care Solutions Limited Vacant Care Home 7 Category(ies) of Learning disability (7), Physical disability (7) registration, with number of places 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One resident may have an additional physical disability Date of last inspection 14th June 2006 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. At present the home had a new manager, who was in the process of making an application to the commission for registered manager. The minimum fee per service user was £ 1040/-per week and the maximum fee per service user was £ 1660/- per week. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This is the report of the unannounced inspection carried out on 20/05/08 by Pursotamraj Hirekar over 6 hours 15 minutes. The acting manager coordinated the inspection, the service manager and quality and compliance manager also supported the process. The method of inspection included study of care plans, risk assessments, staff deployment duty rota, staff profiles, relevant care delivery documents, discussions with staff and people using services, observations of staff and people using services interaction and partial tour of the building. Documentary evidence received from the acting manager, in response to the feedback given on inspection, annual quality assurance assessment (AQAA) – provider’s self-assessment received is included for analysis and preparation of this report as well. What the service does well: What has improved since the last inspection? What they could do better: The registered provider must ensure that at all time correct medication records are maintained for all the people using the services. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 6 The registered provider must ensure that each individual service user has clearly written guidelines for the care that staff provide for them and, that the staff follow this guidance. This has been regularly monitored as part of the ongoing quality assurance. The registered provider must ensure that all the staff working at home receive appropriate training that matches with the assessed needs and risks of the people using the service. The registered provider must deploy appropriate numbers of staff at all times to meet the assessed needs and risks of the people living at the home. The registered provider must make an application for registered manager to the commission. The registered provider should ensure that decoration work is carried to the bedrooms of the people using the service, without delays in the best interests of the service users. The registered provider should evidence that during preparation and review of care plans, families or advocates are included and agree with the care plan provision and delivery. The registered provider should deploy staff member of same gender to support and meet the personal care needs of the male service user living at the home. The registered provider should ensure that the care plan and other related documents are presented in an appropriate format that would enable people with communication needs to understand. The registered provider should ensure that the service users terms and conditions contain fee details and correct address of the commission. The registered provider should ensure that all records are made available for inspection at all times. The registered provider should provide a complaints procedure in an appropriate format that could be used by the people using services with communication needs. The registered provider should ensure that the statement of purpose and the service user guide are provided to potential and existing service users in an appropriate format that matches their communication needs. 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. The summary of this inspection report can be made available in other formats on request. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 7 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.V364260.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using services receive information about the home, are encouraged to visit, and are involved in the assessment process to ensure their needs are met. EVIDENCE: Information about 15 Oakland road is contained in the statement of purpose and service users guide that is comprehensive and reflects the current services, offered to prospective and existing service users. The process for moving into the home, facilities, and choices is detailed including the complaints process. However, the contact details of the commission and new staff and fee details were not updated. The service user guide is given to people when they move to the home as part of the admission process. The information is not in an easy read style, to suit the communication needs of the people using the service. In response to the inspection feedback session, the current acting manager provided additional information after the inspection. This stated that the statement of purpose is being updated and service user guide is available in large print, audio form and widget symbols format, and they would ensure they provide the correct format to individuals requiring it. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 9 One person who has limited verbal communication and is new to the home was case tracked. The Inspector spoke with another person using the services and their care file was checked as part of the case tracking. The care file for the people contained comprehensive pre admission assessments carried out before the admission to the home. This ensures the staff are able to meet care and support needs of that individual. This person also had a trial visit prior to the admission. Individual written contracts were in pictorial format detailing the terms and conditions. However, the fee detail was left blank and the commission’s old contact address detailed. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had developed detailed care plans based on the needs and risk assessments of the people using the service to support in all aspects of their life. There was no evidence of the people using the service and or their representatives’ participation in the care plan preparation and review process, thus limiting the choices of decision making for the people using the service. EVIDENCE: The care documents of 2 people using the service were seen. The care plan outlined the individual need with regard to their personal care needs, support, health care, daily routines, domestic tasks, communication, protection, counselling, transport, cultural issues, finances, and social interests. The 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 11 information was holistic and from the view of the people using the service in relation to their choice of lifestyle, needs and interests. Information was written to help staff to provide the right level of support in relation to promoting independence and skills for daily living such as personal care, domestic tasks, and accessing the community. People using the service said staff knew their routines and choices. The daily routines presented in the care plans reflected in the daily reports of the people using the services. Observations were made of how people using the service communicated with the staff for assistance and support, using the odd word, gestures and pointing to things. The staffs on duty said people using services make their own decisions or are supported through conversation to make their own decisions. People using the services can access social and community activities locally, which include their daily routines; going to their place of work or day centre either independently or transport arranged. Observations made indicated the relationship between people using the services and staff is relaxed, friendly and polite, showing respect to each other when they are talking or expressing a view. Care plans are reviewed six monthly or as and when the need arose and the changes are reflected in the care plan. For example an individual that has had special behavioural needs, his care plan was reviewed and updated to reflect appropriate changes under the protection and transport section. The staff spoken to were aware of the changes to the care plan of the person. The care plans were not presented in an appropriate format to read and be understood by the people using the service with communication needs. Also the care plans could not demonstrate how the family member or advocate were engaged in the care planning and review process. In response to the inspection feedback session, the current acting manager had confirmed in writing to the commission post this inspection that, she would ensure participation from family and others for the forthcoming care plan reviews and every 6 months thereafter. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users experience and enjoy a lifestyle that suits them, being part of the community and having meals of their choice. EVIDENCE: Staff said people moving to the home are supported to continue participating in daily social and community activities. Information about individual daily, social and community activities are detailed in the assessment and included in their care plan. The people using the services confirmed during the discussion both spoken and using gestures, that they continue to participate in daily activities ranging from the day services, going out socially to working. People can choose how to spend the evening and weekends, ranging from seeing friends and family and watching television or films. Activities and daily routines are reflected in the 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 13 daily records and consistent with the interests recorded in the individual care plans and have also matched with today’s activity plan. People using the services indicated, they felt in control of their life at the home and were not restricted in what they did. One person said she was very happy and was excited that she had passed her cooking test and felt very proud of herself, and further said, “I am happy here in this home”. Another person using the service was very keen to show her bedroom to the inspector, especially the new curtains, colour of walls and various decorations she had made to her bedroom to personalise her taste and choice, said ‘this is my room, I am very happy here and with my room’. Staff demonstrated a good understanding of the people they key work, recognising if the person is anxious or unhappy, and how to approach them. One person using the service spoke at length about her day care activities with the inspector. Staffs have received training in preparation and safe handling of food. Staff said they always encourage the people to choose the meals, offering fresh fruit and vegetables, and if necessary showing the food in the box to the service user with limited verbal communication. A mealtime was observed on this inspection, people using the service were encouraged to lay the table and arrange for dinner, service users appeared to be enjoying doing this work. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health care needs are met. One male person living at the home did not have personal care support provided by staff of same gender, thereby limiting his independence and privacy. EVIDENCE: The personal and health care needs of the people using the services are detailed in their individuals’ health care plans, which were presented in a pictorial format, and staffs have guidance in relation to the level of support required, if any. Risk assessments were detailed and included information about personal care, personal hygiene, toileting, medication, technical aids, domestic tasks, walking frame, communication, protection, family counselling, social and day care activities, cultural issues, and challenging behaviour. The people using the service said they were not restricted and were able to continue living the lifestyle of their choosing. There were 2 men living at the 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 15 home with special needs that include personal care for one person. However, the home had no staff member of the same gender on the duty rota. This was discussed with the acting manager during the inspection feedback session, in response the acting manager had confirmed in writing to the commission post this inspection, that the care plan has been updated to indicate that the manager of a sister home of the company would provide 1:1 session time, until the home had employed it’s own male staff member. The home had made arrangements for the people using the service to maintain contact with family and friends. Care plans detailed emergency contacts and health care professionals involved in their care. One person said she is supported to attend health care appointments, if required. The records showed people using the service had regular appointments with the general practitioner, dentist, chiropodist, physiotherapist, psychologist, and opticians. Trained staffs administer medication and staff training records confirmed this. Medication is stored in a locked cabinet with the medication records. The medication for two people using the service was checked, which was consistent with the medication records with minor errors. They include PRN medication for 26th & 28th April 2008 was wrongly recorded on the MAR sheet for a person and for another person eye drops administered on 09/04/08 recorded code G on the MAR sheet, without a written note on the overleaf. The staff on duty demonstrated a good understanding of the medication, people using services take and the importance of having the medication on time. People using the service said they do receive their medication on time. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All staff working at home did not receive appropriate training that matched with the assessed needs and risks of the people using the services at the home. Thereby putting the people using the services at potential risk of harm. Service users interests are protected by procedures and practices for handling money. EVIDENCE: The complaints procedures were not presented in an easy read style for the benefit of people using services that have communication needs. The correct contact address of the commission also was not updated. The people using the services indicated that they were informed of the process of how to make a complaint or express concerns about the provision of care provided at the home. A person said she had not experienced any problems or had any concerns about living at the home. Another person said if I am not happy, I just speak with the manager or my key worker. The home has had 2 safeguarding of vulnerable adults (SOVA) investigations relating to 2 people using the service at the home. One investigation has been concluded, and the agreed actions from the strategy meeting have been reflected in the care plan of the person. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 17 The second SOVA investigation is ongoing. The service manager and the compliance and quality manager from the company stated that in their investigations, it was found that ‘the necessary guidelines, care plans and appropriate communication skills with staff were not in place. Therefore, in accordance with company’s policy, the company had taken disciplinary action against the staff members’ responsible. In respect of the second SOVA case, the commission has received a complaint from the family detailing their concerns regarding the care of their relative. We have sent this information to the safeguarding team at Bedfordshire social services, who are dealing with this case, the investigations are ongoing. The commission continue to monitor the progress on this matter. The home has arranged for the staff to have training on safeguarding and challenging behaviour. On the day of inspection some staff haven’t had not had this training. This was brought to the notice of the acting manager during the inspection feedback session. In response, the acting manager has confirmed in writing to the commission that 2 staff members now have been booked on safeguarding training for 27/05/08 and the other 2 staff members for 03.06/08. Also, these staff members would not work on any care shifts until the safeguarding training is completed. Those trained staff on duty, spoken to, on this inspection, have demonstrated adequate awareness of their role, responsibility, and procedures they are required to follow in relation to any allegation or suspicion of abuse. Staff were confident to whistle-blow poor or bad practice and confirmed that the acting manager is available should any concerns arise. However, these findings should not be linked to the situation and staff members on duty during the incidents at home in February 2008 regarding the second SOVA case referred to in this report. The people using the service can choose to manage their own money if they are able to do so. Records of money transaction were maintained. The acting manager described the process for recording and handling of money for people using services, which ensures the money, is protected. Only the acting manager had access to service users’ money and their records. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a warm, comfortable, clean and a homely environment. EVIDENCE: The home was clean and tidy without any offensive odours and in appearance that suits the lifestyle of the people living there. The lounge/dining room decorated and furnished with domestic furniture that compliments the décor. There is good lighting throughout the home. Individual bedrooms are furnished with bedroom furniture and are close to a shared bathroom. A person using the service showed the Inspector her bedroom, which had been personalised with photographs and toys that reflected her interests and hobbies. The people using the service appeared to be at ease in the home with the staff on duty, choosing to sit in the lounge or going to their bedroom. Information 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 19 received from the registered manager prior to the inspection stated that the home has a rolling programme of maintenance and decoration of the bedrooms and communal areas. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people using the services are protected by staff recruitment procedures, and supervision. There are not always sufficient staffs or staff of the same gender to meet the assessed needs and associated risks of people using the services. This may compromise their privacy and opportunities for independence. EVIDENCE: The interaction of staff with the people using the service was good; there was good rapport, both verbal and non-verbal communication was used. One person using the service praised her key worker. The key worker was aware of the needs of the person’s routines and how best to communicate with them. The home had a good recruitment procedure, having staff appointed upon receipt of two satisfactory references, Protection of Vulnerable Adults (POVA) first check, and Criminal Records Bureau (CRB) check. All the staff records were held centrally. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 21 Staff training records showed a few staff have not received Safeguarding training, in response to the inspection feedback session, the current acting manager has written to the commission about the scheduled staff training (please refer concerns, complaints and protection outcome group of this report for details). On the day of this inspection a female member of staff on duty was providing 1: 1 support to a new male service user, who had learning disability and physical disability needs as well. This person also had personal care needs to be supported by the staff. There were no staff members of same gender on duty rota to support the 2 male people using the service living at the home. The home had a three-shift, staff model in practice. The early and late shift had 2 staff and the night shift had 1 sleep-in and 1 waking staff. The home has had a new admission of a person on the 25/03/08 with a 1:1 staff support requirement. On this day of inspection, 6 people using the service were living at the home. Despite a new admission of one person with 1:1 staff support requirement, the home had not increased the staff numbers. The staff numbers remained the same before and after the new admission. This is likely to have negative impact upon the other people living at the home, if the current staff ratio is maintained. Staff (except one) on duty, confirmed they received supervision. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 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 new acting manager, who needs some more time to consolidate her position. As part of the quality assurance process, the home has good systems and procedures that enable the management to run the home well. However, record keeping procedures need improvement to demonstrate that the rights of people using services are safeguarded. EVIDENCE: The home has a new acting manager who started work on the 21/03/2008. The acting manager appeared to have developed good working relations with 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 23 the staff and the people using the service. Observation made indicated that, she was approachable and polite in her interactions. The various care documents seen on this inspection confirmed there are clear roles and responsibilities in relation to the management of the home and staffing. All policies and procedures are updated, reviewed, and shared with the staff. Staffs were aware of the policies, procedures, and their responsibility. Staff signed information sharing records, confirming they have seen and understood them. The staffs spoken to were confident that either the service manager or the acting manager would be available if there was an emergency. The people using services, spoken to have confirmed that, they are encouraged to express themselves about the running of the home; what improvements are made in relation to their accommodation and décor. Whilst, there is no set time for ‘people using the services’ meeting’ in the home, people can speak with staff at anytime. The home had presented the quality assurance system and procedure, which appeared robust. The quality assurance process covered; weekly activity review and report by the manager, however for the period between 04/02/08 and 18/02/08 the record was not made available on this inspection. The acting manager was not aware, as to why this record was not on the file; she thought this record might be at head office due to the ongoing Safeguarding investigation by the safeguarding team at Bedfordshire social services. The other weekly checks by the manager covered; clients, staff management, vehicle, house, drugs, room temperatures, fire alarm and water temperatures. The home also had monthly checks to be carried out which included; fire evacuation, management checklist, managers walk around, and manager’s spot check report. These checks help in identifying any concerns to the premises; for example the checks carried out on 28/04/08 noted, a person’s bedroom required decoration following loft leak. However, this work is outstanding as on this day of inspection. The acting manager, in response to the inspection feedback session, has confirmed in writing to the commission that, the maintenance work and decoration work is scheduled on priority. The service manager had presented a report of the survey carried out by the home in the month of March 2008. As part of the survey, a questionnaire was sent to people using the service, next of kin, social worker, and staff, to help identify areas of improvement. The data has been analysed and an action plan has been prepared for making improvements, in the best interests of the people using the service. 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 24 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 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 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 3 33 2 34 3 35 2 36 3 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 2 X 3 X 2 2 X 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 25 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. 1 Standard YA20 Regulation 17 (1) a Requirement The registered provider must ensure that at all times correct medication records are maintained for all the people using the services. The registered provider must ensure that each individual people who use this service have clearly written guidelines for providing care by the staff. And, that the staffs have been following the same. The registered provider must ensure that all the staff working at home has received appropriate training that match with the assessed needs and risks of the people using the services at the home. The registered provider must deploy appropriate numbers of staff at all times to meet the assessed needs and risks of the service users living at the home. The registered provider must make an application for registered manager to the DS0000014940.V364260.R01.S.doc Timescale for action 15/06/08 2 YA23 13 (6) 15/06/08 3 YA35 18 ( c ) 30/06/08 4 YA33 18 (1) a 30/06/08 5 YA37 8 15/07/08 15 Oaklands Road Version 5.2 Page 26 commission. 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 YA42 Good Practice Recommendations The registered provider should ensure that decoration work is carried to the bedrooms of the people using the service, without delays in the best interests of the service users. The registered provider should evidence that whilst preparation and review of care plans, the family member or their advocates are engaged in and are agreed with the care plan provision and delivery. The registered provider should deploy staff member of same gender to support and meet the personal care needs of the male service user living at the home. The registered provider should ensure that the care plan and other related documents are presented in an appropriate format that would enable people with communication needs to understand. The registered provider should ensure that the service users terms and conditions contain fee details and correct address of the commission. The registered provider should ensure that all records are made available for inspection at all times. The registered provider should provide complaints procedure in an appropriate format that could be used by the people using services with communication needs. The registered provider should ensure that the statement of purpose and the service user guide are provided to the potential and existing service user’ in an appropriate format that match their communication needs. 2 YA6 3 YA18 4 YA6 5 6 7 8 YA5 YA41 YA22 YA1 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1 Capital Park Fulbourn Cambridge, CB21 5XE 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 15 Oaklands Road DS0000014940.V364260.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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