Inspection on 23/08/05 for 31 Oak Road

This inspection was carried out on 23rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 but made no statutory requirements on the home.

Other inspections for this house

31 Oak Road 29/06/07

31 Oak Road 14/02/06

31 Oak Road 04/10/04

31 Oak Road 06/05/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 31 Oak Road Eaglescliffe Stockton-on-Tees TS16 0AT Lead Inspector Shaun Common Unannounced 23 August 2005 09:30 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 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 Stationary 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. 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 31 Oak Road Address Eaglescliffe Stockton-on-Tees TS16 0AT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01642 391800 01642 391800 Stockton-on-Tees Borough Council Mrs Elizabeth Johnson Care Home 6 Category(ies) of LD Learning disability (6) registration, with number of places 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2004 Brief Description of the Service: Oak Road is a six-bedded care home providing long term care for younger adults with a learning disability. It is situated in a small council housing estate and blends well with surrounding properties and service user accommodation comprises on the first floor of one double bedroom and four single bedrooms. The ground floor accommodation includes a lounge/dining room, a separate lounge and a domestic style kitchen. There is a small garden to the front and a larger one to the rear of the property, which is laid to lawn. The home is close to local amenities and has easy access to the public transport system. 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of Oak Road. The inspection started at 09:30 in the morning and lasted a total of five hours. The inspector talked with one resident and looked around the home as well as speaking to staff and looking at records. Other residents had gone on a day out or were at day centres. Staff and the resident present at the time of the visit were very welcoming. 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. 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 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 standard(s) 1 & 2 Information that informs prospective residents about the home is not adequate. Residents needs are assessed, however this assessment is not effectively used to plan how their needs are to be met on a day-to-day basis. EVIDENCE: The homes statement of purpose and service user guide were examined and had not been updated to meet the required standard, however it was noted that the new manager has begun develop these documents. Files examined contained professional assessments, however the previous manager had not effectively used these is developing appropriate resident plans that identified their needs and how these were to be met on a day-today basis. The new manager had evidence that these were being looked at and would be developed and progressed in the very near future. 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 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 standard(s) 6, 7 & 9 Planning, risk management and reviews are not effectively carried out in order to meet the needs of and protect service users. EVIDENCE: Service user plans examined were not developed from the assessment and did not identify resident’s needs and how these were to be met on a day-to-day basis. The manager again had evidence that work to develop these plans into appropriate working documents was a priority and would be underway very shortly. The last review held on one file examined was dated 8/7/2004 and the minutes demonstrated that only home staff attended and no external professionals. There was evidence on files that demonstrated that residents are fully involved and included in decisions in their lives. One resident had made extensive comments about decisions and recorded these on their file. Risk assessments examined did not identify all matters concerning each resident and those that were identified did not demonstrate action to be taken to reduce the said risk. 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 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 standard(s) Lifestyle was not assessed at this inspection. EVIDENCE: 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 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 standard(s) 19 & 20 Residents’ health needs are identified and met. Residents are assisted and supported to manage their own medication as appropriate. EVIDENCE: Information on files demonstrated that resident’ have regular appointments with relevant health professionals and there was evidence of files being monitored by keyworkers. Medication was appropriately stored and records in place in relation to appropriate administration. One resident was assessed as being able to manage their own medication and this was appropriately risk assessed. Staff had received training in the handling of medications. Accident records were in place and recorded appropriately. 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 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 standard(s) 22 & 23 Policies and procedures that protect residents from abuse are not in place. Residents know how to complain and information regarding complaints is freely accessible. EVIDENCE: A complaints policy and procedure was in place and the information given to residents contained the contact details of CSCI. It was noted that this information was freely available to residents. The complaints record was examined and was appropriate in format and content. A service user who spoke to the inspector said they were aware of how to complain. The manager was interviewed and advised the home has not developed an adult protection procedure nor has the policy on physically intervention been addressed as required at the last inspection of the home. CSCI is aware that the manager of the home is relatively new and has a plan in place to address these issues shortly. A service user who spoke to the inspector stated they felt safe at the home. 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 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 standard(s) 24, 26 & 30 The home promotes service users wellbeing and caters for their comfort. Residents’ safety was at risk due to ineffective window restrictors being in place and these not being monitored by the home. EVIDENCE: A tour of the premises was undertaken and it was noted that all the requirements from the last inspection had been addressed. Oak Road looked well decorated, furnished and homely. Windows have recently been replaced at the home and two of the resident’s bedroom windows were noted to be unrestricted as the measures put in place to restrict them had broken. The home did not have risk assessments in place in relation to this matter. An Immediate Requirement Notice was served to the Registered Manager identifying action that must be taken in order to ensure that resident’s health and safety is promoted and protected. The manager ensured that these two windows were locked shut until the maintenance department was able to carry out effective repairs. One resident showed the inspector their bedroom and stated they were very happy with it. The room was well decorated and furnished as well as being personalised. 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 Page 13 The home was noted to be clean and hygienic throughout. 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 36 Staff are not effectively supervised and therefore formally supported in their role of care delivery. Staff are competent and qualified. EVIDENCE: The new manager has begun to establish supervision and appraisal systems, however has not had sufficient time in post for this standard not be measured since her arrival. Currently, the standard is not met and will be monitored and assessed at the next inspection of the home. Four staff at the home are qualified to NVQ 3 or equivalent from a total of eight. A member of staff interviewed demonstrated knowledge and competency in her role and interactions observed with residents were noted to be positive. 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 43 Quality assurance processes that include the views of residents in improving on and achieving the homes objectives are not in place. The home is financially viable. EVIDENCE: The current manager is relatively new to Oak Road. The manager has planning in place to develop a quality assurance and monitoring system but as of yet this is still not in place. The home has in place appropriate insurance cover and financial accounts demonstrating the viability of the home. The manager is in the process of developing plans for the service in conjunction with her line management. 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 Page 16 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 2 2 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 3 x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x 3 x x x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 31 Oak Road Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x x 3 B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 Page 17 YES 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 1 Regulation 4 Requirement The home must have in place a Statement of Purpose that contains all the elements set out in Schedule 1 of the Care Homes Regulations 2001. The previous timescale of 15/12/04 was not met. The Service Users Guide must be further developed to include the elements set out in Standard 1 of the National Minimum Standards for Care Homes for Younger Adults (18-65). The guide must include the name and contact details of the regulatory body, the Commission for Social Care Inspection. The previous timescale of 15/12/04 was not met. The Registered Manager must further develop service users plans generated from the Care Management Assessment/Care Plan and cover the issues as set out in Standard 6. The previous timescale of 31/12/04 was not met. The Registered Manager must ensure that Service Users Plans are reviewed formally with relevant professionals at least B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Timescale for action 1/11/05 2. 1 5 1/11/05 3. 2, 6 15 1/11/05 4. 6 15 23/08/05 31 Oak Road Version 1.40 Page 18 every six months. 5. 9 13 Risk assessment must contain actions/strategies to be taken in order to minimise risk to service users. The previous timescale of 15/12/04 was not met. Risk assessments must be developed further to cover all assessed risks to service users. The home must develop an Adult Protection Policy/Procedure that complies with the Department of Health Guidance, No Secrets. The previous timescale of 31/12/04 was not met. The home must either review its policy on physical intervention to show that it is not used and demonstrate methods employed at the home for dealing with such incidents, or staff must be trained in accordance with Department of Health Guidleines in physical intervention. The previous timescale of 31/12/04 was not met. The Regsitered Manager must ensure that first floor windows are restricted or there are appropriate risk assessments in place negating the use of restrictors. The Registered Manager must further develop and implement an effective quality assurance and monitoring system as set out in the Standard. The previous timescale of 31/12/04 was not met. 1/11/05 6. 7. 9 23, 40 13 12 1/11/05 15/11/05 8. 23, 40 12 15/11/05 9. 24, 43 13 24/8/05 10. 39 24 15/11/05 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 Good Practice Recommendations B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 Page 19 31 Oak Road 1. 2. Standard 36 All staff should receive formal recorded supervision at least 6 times per year. 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Unit B, Advance St Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 31 Oak Road B51-B01 S36219 31 Oak Road V243642 230805 Stage 4.doc Version 1.40 Page 21 - 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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