Inspection on 11/12/06 for 27 Islip Road

This inspection was carried out on 11th December 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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

27 Islip Road 30/08/05

27 Islip Road 27/04/05

27 Islip Road 07/12/04

27 Islip Road 01/07/04

27 Islip Road 12/02/04

27 Islip Road 02/09/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 27 Islip Road Oxford Oxfordshire OX2 7SN Lead Inspector Stephen Webb Unannounced Inspection 11th December 2006 11:00 27 Islip Road DS0000013094.V317401.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 27 Islip Road DS0000013094.V317401.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. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 27 Islip Road Address Oxford Oxfordshire OX2 7SN 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) 01865 554920 sue.fawcett@advanceuk.org Advance Housing and Support Limited Susan Fawcett Care Home 9 Category(ies) of Learning disability (9) registration, with number of places 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2005 Brief Description of the Service: 27 Islip Road is a large detached house in a residential street in north Oxford, with good access to local amenities. The home is operated by Advance Housing and Support Limited and provides support and accommodation for up to 9 people with learning disabilities, and some associated physical impairment. The home is larger than would be accepted currently as best practice for this client group, and consideration is being given to its long-term future, in this context. Staffing support is provided 24 hours a day. The fees at the time of inspection were £513.07 per person per week including residents contributions. Residents contributions ranging from £62.35-£76.20 per week. All fees are paid direct by by Social and Community Services (The referring body) to Advance Housing & Support Ltd. Social & Community Services then access annually how each resident can contribute to their care, and the resident pays Social & Health Care direct. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 11.00am until 6.00pm on 11th of December 2006. This report also includes reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from conversation with several residents, the manager and brief conversations with staff members. No relatives were present but feedback forms were received from four of them. The inspector examined the majority of the premises, and ate lunch with residents, as well as having conversations with five of them, and made informal observations of interactions between staff and residents at various points during the inspection. The residents are encouraged to have some involvement in the day-to-day operation of the home in terms of household routines, but mostly tend to leave this to the staff. The unit is larger than would be seen as current best practice and this has some impact on the residents as indicated by some of their feedback. The maintenance and redecoration of the unit have not been addressed adequately by the provider, and as the result the environment is unsatisfactory in a number of areas . What the service does well: The needs of prospective residents are appropriately assessed prior to admission. The needs of residents are reflected in the care plans, and residents are involved in their reviews. Residents are enabled and supported to make decisions about their day-to-day lives and are supported to take appropriate risks within an individual risk assessment framework. Information about residents is handled appropriately for the most part, though a system of individual daily notes recording should be reinstated. Residents take part in appropriate activities, and are supported to be part of the local community. Family contact is supported where appropriate and residents are appropriately supported to maintain personal relationships. Independent advocacy is sought where necessary to support the rights of residents. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 6 Menus are planned from day-to-day, led by the preferences of residents, though food shopping and meal preparation is an area where most individuals have little involvement by their own choice. The home effectively meets the emotional and physical healthcare needs of residents and obtains external support appropriately. There is an appropriate management system for medication. Residents were aware of how to complain and felt the staff listened to any concerns raised. Appropriate systems are in place to protect residents from abuse and staff receive appropriate training on these issues. The standard of decor is variable, and staff have attempted to make the best of the given environment and the Christmas decorations were beneficial in this regard, at the time of inspection. Given the decorative conditions, the home was maintained to as good a standard of hygiene as possible. Laundry facilities were adequate. Residents are supported by a competent staff team, who relate well to them. The views of residents have been sought as part of a quality assurance system. The health and safety of residents is protected and promoted. What has improved since the last inspection? What they could do better: The range of different care planning tools and formats should be rationalised to one consistent format. Some areas of the building are in poor decorative order and must be redecorated as a priority. Some lounge furnishings also need to be replaced. Bathing and toilet facilities are poor and specialist equipment identified as beneficial to the needs of two of the residents must be provided. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 7 Staffing levels need to be reviewed to ensure they support residents’ reasonable access to the community at all times. Improvements are needed in the available recruitment records within the unit. The quality assurance system needs to be extended to seek feedback from relatives and other stakeholders, and a summary report needs to be provided to participants. Any outstanding required safety testing or servicing must be carried out to ensure the safety of the premises. 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. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 8 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 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 9 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): Standard 2: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of a prospective resident are assessed prior to admission. EVIDENCE: The manager undertakes a detailed needs-assessment to an organisational format and also obtains reports from relevant specialists, on a prospective resident before deciding a place can be offered. This process was under way for a prospective referral at the time of inspection. 27 Islip Road DS0000013094.V317401.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): Standards 6, 7, 9 and 10: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs, aspirations and goals of residents are reflected in the care plans, and residents are involved in their review. However, the range of different care planning tools and formats would benefit from rationalisation to one consistent format to ensure that the most current information is readily available. Residents are enabled and supported to make decisions about their day-to-day lives and are supported to take appropriate risks within an individual risk assessment framework. Residents’ information is handled appropriately for the most part, though the daily notes on residents are currently recorded within the collective handover record. This is inappropriate in terms of confidentiality, and the notes cannot then be retained as part of individual case records. A system of individual daily notes recording should therefore be reinstated. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 11 EVIDENCE: Detailed individual care plans were in place across a variety of different formats, including essential lifestyle plans, which appeared to be the core of the current system. Whilst they did contain a lot of good detail, the variety of formats was potentially confusing. It may be prudent to establish one consistent system and fully complete the associated formats and archive the other versions, to ensure that the most current information is readily evident. There was evidence that the likes and dislikes, goals and wishes of residents were addressed within the various care plan formats, and this information should be included in whatever format is retained. Action plans were present on file detailing targets and recording progress towards these, and there was evidence of regular reviews taking place, including the resident. The review format includes some pictures to support the written information. There was evidence of the consultation of residents and the inclusion of their goals and wishes within care planning documents, as well as clear guidelines on any necessary support, together with a range of appropriate risk assessments. Residents’ choices regarding how they are supported are also recorded within care plans, and there were signed agreements about aspects of care support and consent forms regarding the management of residents’ funds. The daily notes on individual residents were mostly being made within the collective handover sheets, which means that a lot of valuable day-to-day information is lost into storage, and is not readily available to staff or part of individual case records as it should be. The old individual diaries had only sporadic entries for out of the ordinary events, with extended gaps between these entries. The manager should consider reinstating an individualised daily record system for each resident, where the majority of recording is made. These can, if necessary be individualised to reflect aspects of the work with individuals, such as monitoring of self-care events, behavioural issues or work towards individual care plan goals. The handover sheets should contain only a brief summary of any incidents of note, and refer to the daily record for detail. 27 Islip Road DS0000013094.V317401.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): Standards 12, 13, 15, 16 and 17: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to take part in appropriate activities, and are supported to be part of the local community. There are plans to increase resident’s opportunities within the community, which may necessitate a review of staffing levels, with particular reference to periods of single staffing of the unit, despite the level of independence of most of the residents. Family contact is supported where appropriate and residents are appropriately supported to maintain personal relationships. The home accesses independent advocacy where necessary to support the rights of residents. Menus are flexible and led by the preferences of residents, though this is an area where most individuals have little involvement by their own choice. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 13 EVIDENCE: Residents confirmed that there were opportunities for in-house activities and that they could access the local community. The ethos of the unit is to encourage and support residents to seek out activities of their choice for themselves, rather than these being laid on routinely for them. Staff were seen encouraging residents to take decisions for themselves and supporting this where necessary in a relaxed way, and relationships between staff and residents were appropriately adult. One resident had been supported to put up the unit’s Christmas decorations during the previous weekend and proudly showed them to the inspector. Some resident’s access regular day-services and one has attended a college course. One had paid employment until recently when he was made redundant, and another does voluntary work for Oxfam. One of the residents attends church unsupported when they wish, but no spiritual needs have been identified for the other residents, though the option is offered to them. Six of the eight residents can access the community without staff support in specific circumstances, and risk assessments were in place. However, some residents and relatives felt that at times the levels of staffing limited the ability of residents to access the community. Only one staff member is on duty from early evening until the following morning most days, so this may need to be reviewed if it can be identified as limiting community access. It may well be necessary to provide additional staffing at specific times given that it is the manager’s stated intention to try to encourage greater access to the community and involvement in daily living tasks such as shopping. On occasions additional staff are already rota’d for specific activities. Resident’s contact with family and friends is supported where appropriate though sometimes the staff advocate for the right of residents to make their own decisions and choices. Residents are also appropriately supported to be able to maintain their own chosen relationships. Where the views of the resident and the family cannot initially be reconciled, the home accesses appropriate external advocacy for the resident to provide impartial support for them. It was reported and confirmed by some of the residents, that most take relatively little part in food shopping for the home or meal preparation, despite encouragement, though the manager was hoping to increase the level of involvement in these areas. One resident prepares some of her own meals with support where necessary. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 14 Three of the residents confirmed that they enjoyed the meals provided and could choose meals that they enjoyed. The menu is not planned in advance but selected on the day reflecting individual choices. The subject of menus and shopping is raised within residents’ weekly meetings. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 15 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): Standards 18, 19 and 20: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate personal support is provided to residents with due regard for the preferences of individuals, within an overall context of enabling and supporting self-care wherever possible. The home effectively meets the emotional and physical healthcare needs of residents and obtains external support appropriately. One resident is supported to manage their own medication within a risk assessment framework, and the home has an appropriate management system for the medication of others. EVIDENCE: Personal support is provided appropriately, with the emphasis on self-care wherever possible. Support is provided behind closed doors. This was confirmed by residents who also confirmed they had their own bedroom and front door keys. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 16 As already noted, external advocacy support is sought where necessary on a task-related basis, where issues of conflict arise. Appropriate records of seizures were in place for one of the case-tracked residents, and a health action plan had been completed. The secondary mental health needs of two residents are supported via the local CTPLD and an additional fifteen hours per week staffing is provided for one resident to support their additional needs around anxiety. Healthcare records were appropriately individualised and maintained. There was evidence of detailed and appropriate after-care for one resident following an operation, including the provision of additional staffing to cover the postoperative convalescence period, and also of consultation and support to prepare a list of questions for the GP prior to the operation, to address the resident’s anxieties. The unit were in the process of completing “Keeping Healthy and Safe” booklets for each resident but the process was yet to be completed. One resident manages their own medication for epilepsy, with appropriate monitoring and support, following an appropriate risk assessment, which is periodically reviewed. The unit has an appropriate system in place for managing the residents’ medication, which provides an audit trail. Records are also maintained of any homely remedies given. A pharmacy audit was undertaken in November with positive findings. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 17 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): Standards 22 and 23: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were aware of how to complain and felt the staff listened to any concerns raised. The records supported this. The unit has systems in place to protect residents from abuse and the staff receive appropriate training on these issues. EVIDENCE: The home has an appropriate complaints procedure, which is explained to residents and posted on the notice board in the entrance hall. Evidence was on files of residents signing to confirm they had had the complaints procedure explained to them. Some informal complaints were recorded about the interactions between residents and other issues, which appeared to have been investigated appropriately. All of the current residents would be able to make a complaint should they wish to, and most confirmed they were aware of how to do so, and that staff listened to any concerns they had. Appropriate financial management systems were in place together with signed consents, to protect residents’ finances. Almost all of the staff had received training on the protection of vulnerable adults (POVA) and some had also attended other related courses. 27 Islip Road DS0000013094.V317401.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): Standards 24 and 30: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment is adequate overall, but some areas are in poor decorative order and must be redecorated as a priority. It is not satisfactory to put off necessary redecoration due to uncertainty about the unit’s future, or because the area is not due for refurbishment according to an arbitrary maintenance schedule. The staff have attempted to make the best of the given environment and the Christmas decorations were beneficial in this regard, at the time of inspection. Bathing and toilet facilities are poor and the specialist equipment identified as beneficial to the needs of two of the residents must be provided. Given the decorative conditions, the home was maintained to as good a standard of hygiene as possible, though there was some evidence of odour in some areas. Laundry facilities were adequate 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 19 EVIDENCE: The entrance hall is welcoming and the previous inspection reports, complaints procedure and visitors policy are displayed within. Two residents share a bedroom by their choice and there are plans to convert the second bedroom into a private lounge for them, which is appropriate to address their needs. However, funding is not reportedly available to decorate this room at present, within the planned cycle of redecoration, and the manager has no delegated authority to authorise the completion this work. The couple’s bedroom is also in need of redecoration, along with others in the home, where the decorative standard is not satisfactory. It is understood that family have also made informal complaints about the decorative condition of these facilities. It is understood that some bedrooms have not been redecorated for a number of years. It is not appropriate to delay necessary redecoration on the basis of sticking rigidly to scheduled decoration programmes. All areas are required to be maintained in a reasonable decorative state. (Regulation 23(2)(d). The bedrooms seen were, however, appropriately individualised for residents and were equipped with cd player, television etc. It is also positive that residents have their own bedroom and front door keys. It was reported that the long-term future of the unit is under discussion by the provider and it appears that necessary ongoing redecoration is falling behind as the result, in terms of the standards of décor, condition of bathroom and toilet facilities and flooring, which are dated and drab. The bathroom and toilet flooring is old and is not sealed around the appliances. The floorboards in the bathroom are uneven and insecure, and may be deteriorating as the result of water penetration. The grouting in the shower was also mouldy and in need of replacement, presenting a potential health hazard, and the room may require more effective extraction to prevent a recurrence. An OT assessment has reportedly indicated that two residents would benefit from the provision of a bath pole in the bathroom, but the organisation has declined to fund this. It is a requirement that the necessary equipment and adaptations are provided to meet the needs of residents accommodated, and this should not be at the expense of residents. (Regulation 23(2)(a) & (n)). 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 20 The lounge/dining room was attractively adorned with Christmas decorations and adequately decorated, but the soft furnishings provided were worn and damaged. Most had been covered with throws to disguise this, and some other repairs had been done to try to extend the life of some items. This furniture requires replacement. Uncertainty about the unit’s future need not delay this as any items bought could be relocated to other premises. There is a second communal room, which used to be the dining room, but had become the smoking room for one resident who is a smoker. It is a shame the use of this room is so limited, and the manager is considering alternative arrangement for smokers’ provision. A smaller quiet room is also available, which contained a keyboard, guitar and music centre. This room was also in need of redecoration, which was said to be due. There is a secluded and enclosed rear garden, which provides areas of lawn patio and pathways. The unit receives some gardening support to maintain it, in the absence of resident interest in its maintenance. Laundry facilities are cramped but appropriate for the current needs of residents, though a crack had recently appeared in the wall in the utility area. Given the decorative conditions, the home was maintained to as good a standard of hygiene as possible, though there was some evidence of odour in some areas. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 21 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): Standards 32, 33, 34 and 35: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a competent staff team, who relate well to them, but there is a need to review the lone staffing situation, in terms of whether it is detrimental to residents’ reasonable access to the community at these times. Improvements are needed in the available recruitment records with respect to providing adequate evidence that CRB’s are at the enhanced level and that POVA checks have been done. EVIDENCE: The observed interactions between staff and residents were positive and relaxed and the staff demonstrated a good understanding of the needs of individuals and adopted an individualised approach. The majority of feedback from residents was also positive about the approach of staff and them listening to the residents, though some felt their was a need for more staff to improve access to the community. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 22 Progress has been made on NVQ with three staff having NVQ level 3, and two more waiting assessors, one has a relevant alternative qualification and four are undertaking their LDAF foundation training. The presence of only one staff member from early evening through to the following morning most days may need to be reviewed in this context as already noted. (Requirement made under Standard 13). Examination of a sample of recruitment and vetting records indicated that an appropriate system was in place for the most part, but the absence of available detail on site, regarding CRB and POVA checks was of concern. The CRB confirmation letter present did not confirm that CRB’s were at an enhanced level, not whether a POVA check had taken place. It was good practice, however, that interview records, copies of ID confirmation and references had been retained. An ex resident had been involved in the last recruitment process, and residents have since been asked what they want from a staff member, and these issues will be raised as part of the next interview process. Prospective appointees are invited to visit the unit to meet the residents informally under staff supervision, to observe their ability to interact with effectively with residents. The training spreadsheet indicates that appropriate core training has been provided, which was confirmed by staff. All of the staff had attended recent POVA training, by an accredited trainer, apart from the most recent appointee. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 23 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): Standards 37, 39 and 42: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ benefit from a well-run home at manager level, but there is evidence that the funding necessary to maintain the environment to a satisfactory standard, is not being made available by the provider. Requirements for action to address these issues have been made elsewhere in the report. The views of residents have been sought as part of a quality assurance system, but this needs to be extended to relatives and other stakeholders, and a summary report needs to be provided to participants. The health and safety of residents is protected and promoted, for the most part, but any outstanding safety testing must be carried out and certified. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager is suitably experienced and is working towards her NVQ Level 4 and Registered Manager’s Award. However, the provider delegates a limited degree of financial authority to the manager, preventing operational priorities being addressed effectively, and does not appear to be making the necessary funds available to maintain an adequate standard of environment, owing to uncertainties over the unit’s future. Requirements for necessary expenditure have been made elsewhere within this report. Examination of a sample of health and safety-related certification indicated that some servicing etc. was overdue. No current certification was available for the annual electrical appliance testing, nor was a copy of a current certificate for the periodical examination of electrical wiring and installation. A current gas safety certificate was, however, present. Individual copies of accident records were present on residents’ files as required and a collective accident record was also in place for monitoring. As already noted, a range of appropriate individual risk assessments was in place, with evidence of their periodic review. There are also regular residents meetings chaired by a consistent staff member for continuity, and minuted with the inclusion of some pictures. The home does access support from independent advocates but this is on an as-required basis rather than an ongoing situation. The manager undertook a quality assurance survey in 2006, focusing on the residents, receiving mostly positive responses, though the issue of wanting more community access also emerged here. The summary report for this cycle had yet to be completed at the time of inspection. No recent survey of relatives and stakeholder has taken place, and this should be undertaken as part of the quality assurance cycle. The Oxfordshire Quality Monitoring audit had taken place, and the resulting report was available. Copies of CSCI inspection reports were available in the entrance hall, and had been sent to next of kin. Regulation 26 monthly monitoring visits are now taking place monthly and the resulting reports are filed in the unit, though there had been a two month gap and some of the previous reports had lacked substance in the area of resident consultation and feedback. This had improved in recent reports. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 25 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 X 2 2 3 X 4 X 5 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 YA13 Regulation 18(1)(a) Requirement The manager must review the staffing levels to ensure they do not inappropriately limit resident access to the community. The provider must arrange for redecoration/refurbishment of the identified communal areas, bathing facilities and bedrooms to bring the environment up to an acceptable standard. The provider must provide the bathroom adaptations identified as beneficial to meet the needs of residents. The manager/provider must ensure that the potential health and safety risk presented by the mould in the shower is addressed effectively. The provider must provide soft furnishings of an appropriate standard in the lounge. The provider must ensure that evidence is available on-site to confirm that appropriate staff vetting has been carried out. The manager must ensure that any outstanding required servicing and safety checks are carried out and certificated. DS0000013094.V317401.R01.S.doc Timescale for action 11/03/07 2. YA24 23(2)(b) & (d) 11/03/07 3. YA24 23(2)(a) & (n) 13(4) and 23(2)(d) 11/03/07 4. YA24 11/12/06 5. 6. YA24 YA34 23(2)(c) and (g) 19 & Sched. 2 13(4) 11/03/07 11/12/06 7. YA42 11/01/07 27 Islip Road Version 5.2 Page 27 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. 2. 3. Refer to Standard YA6 YA10 YA39 Good Practice Recommendations The manager should consider rationalising the variety of care plan formats to one consistent system. The manager should consider the re-instatement of an appropriate individualised system for the recording of daily notes on residents. The manager/proprietor should extend the quality assurance system to relatives and other stakeholders and make a summary report of the findings available to participants. 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 27 Islip Road DS0000013094.V317401.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!