Inspection on 01/12/05 for 56 Oakwood Road

This inspection was carried out on 1st December 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

56 Oakwood Road 21/11/06

56 Oakwood Road 09/06/05

56 Oakwood Road 29/09/04

56 Oakwood Road 19/04/04

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

CARE HOME ADULTS 18-65 Oakwood Road (56) 56 Oakwood Road Horley Surrey RH6 7BU Lead Inspector Pat Collins Unannounced Inspection 1st December 2005 12:30 Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Oakwood Road (56) Address 56 Oakwood Road Horley Surrey RH6 7BU 01293 775132 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) The Avenues Trust Limited Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 39 65 YEARS 9th June 2005 Date of last inspection Brief Description of the Service: 56 Oakwood Road is a care home providing personal care for six adults with learning disabilities. Currently the user group is all male. The Avenues Trust operating this home is an organisation providing care establishments for adults with learning disabilities in Surrey and Kent. The house is a detached, two storey property which is domestic in style and character. It has off street parking to the front of the building. There is a large, enclosed garden to the rear of the building with summer - house and garden furniture. The home is located in a residential area, close to Horley town centre and is convenient for public transport and all community facilities. Bedroom accommodation is all single occupancy, situated on the first floor, accessible by stairs only. The bedrooms are of a good size and have been decorated and personalised to reflect the taste and interests of occupants. Two large bathrooms and a quiet sitting area are also provided on the first floor. Communal areas on the ground floor comprise of a fitted kitchen, separate utility/laundry room and large, open plan combined dining / sitting room. An office facility is also located on the ground floor. Service provision includes a seven - person ‘people carrier’ model vehicle for the sole use of the home. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s second inspection for the year 2005/2006. This was an unannounced visit, which meant staff and service users were unaware it was to take place. The inspection commenced at 12.30 hrs and was concluded at 17.30hrs. At the outset there was one service user present in the home and one support worker. The manager and remaining staff on duty had gone out for lunch with the other service users. The service user remaining in the home had chosen to stay home. Volunteers were on the premises redecorating the dining room with a supervisor from the Community Service programme. The manager and senior support worker returned with three service users at 13.30hrs. Two service users had gone on to attend a planned activity session at a day centre, returning home later that afternoon. The inspection process involved individual discussions with the manager and with the three staff on duty. The inspector saw all six service users. Due to the communication difficulties of the service users living in this home it was not possible to obtain their views about the home or their care. Some practice observations were carried out, specifically interaction between staff and service users. Requirements from the last inspection were reviewed and some records sampled. These were service maintenance and risk assessment records, the staff rota, staff training records and care documentation including ‘person centred plans’, thereafter referred to as care plans in this report. Medication storage, administration practices and record keeping was also examined. A tour of the premises was conducted. Comments received from a professional and a relative about the home following this inspection also formed part of the inspection process. The inspector would like to thank the service users for their courtesy in allowing the inspector access to their home. Also the manager and staff on duty for their cooperation and hospitality. What the service does well: The home had a stable, albeit depleted, core staff group, affording continuity of care and a consistent approach to behaviour management. The staff on duty had established good rapport with service users and demonstrated a clear understand of their individual needs. This is particularly important to the wellbeing of service users in this home given that only one service user verbally communicated his needs and his vocabulary was limited. Staff were skilled in their use and understanding of non -verbal forms of communication. They used gestures and signs, visual and situational cues to support and enable service users to express themselves. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 6 Staff were friendly and caring in their approach towards service users. The atmosphere was calm and welcoming. An age - appropriate, learning environment was evident, commensurate with service users’ levels of understanding and individual capabilities. The risk management strategies sampled were appropriate, aimed to minimise risks related to medical conditions, behaviour management, and activities in the community and in the home. Care documentation sampled and information from the manager and staff, suggested that staff worked hard to establish and respond to service users’ preferences in daily activities of living. This was evident from information available about domestic routines, social and leisure activities and the approach to personalising, decorating and furnishing service users private space. Personal care and support and health care needs had been identified using comprehensive needs assessments. Where practicable this process was in consultation with service users, the degree determined by individual capacity. Relatives and/or advocates of service users, relevant agencies and where necessary, specialists, were involved in care plan reviews. It was demonstrated that a service user had been actively involved in mapping an ‘essential lifestyle plan’ which formed the basis of his care plan and the map was displayed on his bedroom wall. Service users benefited from individualised, suitably structured activity programmes. These afforded opportunities for establishing relationships with other people, including peers, outside of the home. The activities programmes included sessions spent at specialist day centres in the community. Additionally service users received services provided by Surrey Oakland’s NHS Trust day services team. The daily operation of the home promoted integration in the local community, facilitating access to suitable community resources and amenities. Service users had opportunity to go away on holidays. Five of the six service users had enjoyed supported holidays this year with staff from the home. The service user who did not go on holiday had refused to go. This was part of this individual’s behaviour pattern and was being addressed through individualised behavioural programmes and care planning. Care practices ensured service users health and personal care need were met and medication storage and practices were in accordance with statutory requirements. Positive comments were received from a professional who has contact with staff and service users. It was stated that staff were friendly and communicate between the home and this service was good; also that service users seemed happy and well cared for. What has improved since the last inspection? It was positive to note management stability at the home following a protracted period in which there was a high turnover of managers. This was inevitably disruptive in respect of constant changes at the home as a Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 7 consequence of difference in management styles and opinions. The current manager had been in post since October 2004. She had relevant management qualifications and was suitably experienced in the care and support of adults with learning disabilities. The impression was gained of the manager being well supported by two experienced senior support workers. Statutory requirements made at the time of the last inspection had been met. These related to an amendment to service users’ contracts, attention to water damage to the kitchen ceiling and replacement of a bathroom lock. Cleaning substances were securely locked away and food stored in the fridge was labelled with the date of opening. Fire safety audit systems had been improved to include weekly inspection of fire doors and self - closing devices. A new practice had been introduced for the daily monitoring and recording of medication storage temperatures. Staff had individual training and development profiles. An ongoing programme was evident of NVQ training, statutory and service specific training also training accredited under the Learning Disability Award Framework. The senior support worker on duty was a registered nurse (learning disability speciality). The large rear garden had been cleared and tidied since the last inspection and was now regularly maintained. A raised flowerbed had been created and staff were planning a sensory garden and in – house garden project involving service users. Brambles and bushes had been cleared from near the front door and front garden. This had enhanced safety, as there was now room to turn vehicles and staff no longer needed to reverse out of the drive onto the road. There was an ongoing redecoration programme and a quiet sitting area had been developed on the landing. This had enhanced the home’s facilities to the benefit of service users. 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. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 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 Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. At the time of the last inspection in June 2005 the home found to be operating effectively in respect of standards 1, 2 and 5. EVIDENCE: Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Evidence gathered at the time of this inspection demonstrated these standards were met. Care plans and risk assessments were clearly recorded and regularly reviewed and information handled appropriately. Individuals were encouraged to make decisions in their daily lives with support. EVIDENCE: Planning meetings for reviewing care plans had taken place and it was stated that outstanding planning meetings were booked. Review meeting dates had to be changed for reasons outside the home’s control. The care documentation sampled was up to date, in good order and contained framework and holistic profiles. The manager described ways in which a service user had been enabled to express his preferences at his recent review meeting and engage in mapping his needs. Record storage was secure. Sensitive personal information about service users was stored in a locked filing cabinet. Care profiles including care plans were stored on open shelving in the office. The manager stated that the office was locked when not occupied or directly observed. Staff’s personnel files were securely stored and access was restricted to the manager. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14. The home met each of these standards. The day-to-day operation of the home promoted independence within individual capabilities and risk management strategies. Service users were supported in developing social, emotional, communication and independent living skills. Though the organisation of a variety of activities that are appropriate and developmental was challenging due to the needs of the service users at this home, observations confirmed good teamwork and coordination of services, enabling service users to lead fulfilling lives. EVIDENCE: Service users were enabled to use community facilities. They each had structured day care programmes with visual details of types of activities displayed on the wall in the office. Individual’s enjoyed walking and other outdoor activities, swimming, social groups, line dancing, music workshops, driving a horse and cart and other activities organised and facilitated by Surrey Oakland NHS Trust day services team and staff from the home. Provision included aromatherapy in the home by a visiting trained therapist. A service user was encouraged and supported to engage in the care of the home’s pet rabbit. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 12 The manager confirmed that two service users must have a 2:1 staff ratio when travelling in the home’s vehicle and out in the community. One service user required additional observation at all times when in the home. Currently an additional support worker was deployed 20 hours a week specifically to supplement staffing levels to ensure provision of the required staff ratio was made for continuity of the activity programme. His role focused on meeting social and recreational needs and enhanced opportunities for new learning experiences. He was stated to be currently introducing individual service users to use of public transport. Service users with the exception of one had enjoyed small group holidays this year with staff support. These holidays had evidently been managed successfully to the benefit of service users. Staff and the manager described the risk assessment processes underpinning holiday plans, which appeared comprehensive and adequate. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21. There was evidence of personal and health care needs being met and sensitivity in approach to families when establishing their wishes specific to ageing, illness and death. Service users health needs were identified and addressed. Risks associated with health – related conditions were assessed and appropriately managed and subject to regular review. The changing needs of service users were promptly identified and suitably assessed. Medication storage was secure and medication was administered by suitably trained staff and accurately recorded. EVIDENCE: Medication storage, administration and record keeping sampled was in accordance with statutory requirements and guidelines issued by the Royal Pharmaceutical Society. The home had metal medication cupboards including one for controlled drugs though there were no controlled drugs prescribed at the time of the inspection. None of the service users’ had capacity for selfadministration of drugs and this was the role and responsibility of staff. There was a medication-training programme, which included an element of assessed practice. Clear protocols were in place relating to administration of medication prescribed ‘as required’. The home had a monitored dosage medication system and had changed supplier since the last inspection. The pharmacist carried out annual audits of the home’s medication system. A new policy and system had been introduced for daily monitoring of the temperature in medication cabinets Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 14 to ensure safe storage. Discussed with the manager was the need to update the signatory record for staff trained in administration of medication. Service users were stated to have medication reviews at six-monthly intervals. Risk assessments and risk management strategies were in place for the management of epilepsy. Night monitoring equipment was used and hourly checks carried out by support workers for service users with a history of seizures. The medical practice had a nurse specialising in epilepsy who monitored these individuals and offered advice and support to the team. The protocols for the management of seizures and action to be taken when summoning assistance from para - medics was explicit. Medication for rectal administration of medication in the event of multiple seizures was not held in the home. The instruction in these protocols to staff was to inform emergency ambulance services of the need for this medication to be brought with them for administration. On arrival there was one service user and a support worker present in the home other than a number of community service workers decorating the dining room. The support worker was observed to interact with this service user in an age-appropriate manner. The remainder of the service users had gone out to lunch with the manager and two staff and from there planned to go on to take two service users to The Croft day centre for a planned activity. Practice observations during the inspection indicated positive relationships between staff and service users. Discussions held with staff confirmed a clear understanding of service users individual needs. Staff demonstrated commitment to enhancing service users’ quality of life by offering a varied programme of activities. Service users appeared comfortable in staff’s presence and were able to communicate their needs through gestures and sounds. One service user was able to verbally communicate his needs though his vocabulary was limited. Service users had varying degrees of independence and had unrestricted access to their bedrooms. Staff provided supervision and support to the level necessary to meet individual needs. A staff member was upstairs on the landing, unobtrusively ensuring the wellbeing of two service users who were in their bedrooms. One was resting on the bed before supper, listening to music and enjoying the relaxing environment, enhanced by sensory equipment. The age range of service users living in this home is between 40 and 60 years. The changing needs of service users associated with ageing and medical conditions were evidently kept under continuous review. The manager confirmed that for service users with relatives, that they had been consulted to explore their wishes in the event of terminal care and death. A report was awaited following a recent assessment of the environment carried out by Surrey Association for Visual Impairment. This had been sought in response to the changing needs of a service user who was going through the process for Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 15 being registered as totally visually impaired. All service users were able to manage stairs. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home had a clear complaint procedure, which included stages of, and time scales for investigation of complaints. EVIDENCE: The organisation had a robust complaint procedure that had been produced in various formats including a pictorial format. Unfortunately the complaint procedure was not accessible to the service users in this home due to levels of understanding and communication problems. The staff team were noted to be adept at understanding non – verbal forms of communication and would be able to identify if service users were unhappy. Service users were seen to confidently approach staff to make their wishes known to them. There were no complaints recorded since the last inspection. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The premises afforded service users a comfortable, clean and homely environment that is domestic in scale and character. Action was being taken to create a positive and enabling environment for a service user who had a visual impairment. EVIDENCE: Overall the building was well maintained and there was a rolling programme of redecoration and refurbishment. Furnishings were of good quality and in good condition. Bedrooms were well personalised reflecting the taste and interests of individual occupants. Safety precautions included low surface temperature radiators and valves fitted to control hot water at a safe temperature. Window restrictors were used for the safety and security of service users. The open plan dining area was being redecorated at the time of the inspection. All areas of the home were clean and tidy. It was noted the kitchen ceiling was stated to have been repaired and redecorated since the last inspection. A further flood however in the bedroom above the kitchen caused by the behaviour of a service user had further stained the ceiling. The manager confirmed that this had been reported and there plans to redecorate again. Preventative measures were stated to have been instituted to minimise risk of further floods. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 18 The rear garden had been cleared and was well maintained at the time of the inspection. A raised flowerbed was a new development and the manager confirmed the intention to plant a sensory garden next year, involving service users. Brambles and bushes had been cleared from the front garden. This had extended the area for turning vehicles, which had improved safety standards as staff no longer needed to reverse out of the drive onto the road. Since the last inspection a quiet sitting area had been created on the landing. This had been tastefully furbished to coordinate with the décor in this area. The Fire Officer had recently visited the home and had raised no concerns about this new development. Requirements made by the fire officer in recent reports had been addressed. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 There were long - term support worker vacancies. The shortfall in staff hours was covered from within the team and use of regular care bank staff. The depleted staffing establishment and shortage of approved drivers for the home’s vehicle sometime resulted in difficulties in covering shifts and planning the staff roster. The manager was included in staffing levels with the exception of five hours per week. Discussed was the importance of monitoring time spent over and above these five hours on management and administrative tasks, including meetings, to ensure this does not significantly detract from available care hours. Staff were competently meeting the needs of the service users and benefited from an effective training and development programme. EVIDENCE: There were three full time support worker vacancies at the time of the inspection. The manager stated that the organisation was recruiting new staff and anticipated new staff allocated to the home in January 2006. With the exception of three support workers and the manager, the remaining staff had worked at the home for a number of years. Discussions with staff revealed they were well motivated and committed to supporting service users in achieving maximum independence. Shortage of approved drivers for the home’s vehicle was an additional problem. On the day of the inspection the home only had only two approved drivers on the team, one of whom was on leave. Whilst four service users regularly were taken out by day services staff in vehicles supplied by Surrey Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 20 Oaklands NHS Trust it remained that drivers were essential within the team for transporting service users to and from a day centre in Reigate. A vehicle was also essential for other activities, for example food shopping and banking. The manager advised that she was reluctant to authorise use of staff’s own vehicles for business purposes on account of budget implications. Staff training and development assessments were examined and records of staff training. Evidence was found of relevant induction and statutory training for all staff. An NVQ training programme was also well established. The training and development plan was linked to the home’s service aims and to service users’ specific needs. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42. The management direction to the team appeared consistent, ensuring service users received the support and care necessary to meet individual needs. Effective quality assurance systems ensured continuous self – monitoring of standards at the home. The welfare and safety of service users was overall promoted through effective service and maintenance arrangements underpinned by risk assessments. Discussed was the need to further develop the home’s fire risk assessment. EVIDENCE: There was a long history of high turnover in managers and inevitably the constant changes and various interim management arrangements had been disruptive. The current home manager was appointed in October 2004 and was not yet registered owing to substantial delay in submitting an application for registration and application for CRB through the Commission. This standard is not fully met on this basis. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 22 Observation made of the home’s management and administration indicated that this was efficient and effective. The manager received support from two experienced senior support workers. Policies, procedures and systems were in place to ensure safe working practices. Risk assessments were carried out and recorded for all safe working practice topics including fire risk assessments. Requirements made at the time of the last two inspections by the community Fire Safety Officer had been met. The manager confirmed that weekly inspections were now carried out of fire doors and self-closing – devices. The need to further develop the fire risk assessment was discussed with the manager. Additionally, recommendation was made for a checklist system to be instituted and person designated daily responsibility for inspecting and clearing the tumble dryer filter. Arrangements for service contracts and for repairs appeared adequate to ensure maintenance of a safe environment. Records sampled included all fire records, health and safety audits and gas service records. Portable electrical appliance testing was last undertaken in December 2004 and imminently due to be carried out again. The manager was unable to locate a current electrical certificate and agreed to forward a copy to the Commission following the inspection. The manager stated that the business and financial plan for the home was under review. Discussed was the importance of considering the adequacy of five hours supernumerary management time as part of this review to ensure management time did not detract from hours available for provision of care and support to service users. The manager confirmed that she sometimes used her supernumerary hours working from home where there were fewer distractions. Though included in the staffing levels at all other times it was stated that there was capacity to spend time on management and administration tasks in the afternoons. Discussions relating to the home’s management structure identified omission of posts for senior support workers within the staffing establishment and budget. The manager confirmed that this was being addressed currently by diverting funds from other budgets to fund two senior support worker posts that were created and filled through promotion, seven months ago. These new posts were essential to the effective management of the home. It was anticipated that the staffing establishment would change accordingly in the new financial year and the budget increased. Observations confirmed some recent shifts that had been below minimum staffing levels. The senior care assistant responsible for the rota confirmed this had not been planned but due to short - term sickness. Though there is a care bank of regular staff known to service users, which is crucial in this service to minimise risk of behavioural incidents, care bank staff were not always available at short notice. The manager stated that she had worked additional hours to cover the shortfalls though not the whole shift. Any additional hours worked by the manager should be reflected on the rota in order to identify Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 23 staffing shortfalls and for monitoring staffing levels. Though an additional difficulty in managing staff absences, good management practice was noted in the restriction of overtime hours to ensure safe working practices. Quality assurance systems and auditing tools were used for continuous selfmonitoring of the home’s performance. Also for measuring success in meeting the service aims. Monthly provider visits were carried out by external management on behalf of the responsible individual and reports from these visits shared with the manager and the Commission. An annual survey was carried out by the organisation, eliciting views of service users though not possible in this home, and relatives/advocates. Questionnaires had been sent out this year to relatives/advocates and three were returned. Not all service users had family contacts and some relatives were unable to visit frequently. The content of the returned questionnaires indicated satisfaction with standards of care at the home and with communication from the home. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Oakwood Road (56) Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 2 x 3 x 3 2 x DS0000013521.V257361.R01.S.doc Version 5.0 Page 25 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 2 Standard YA24 YA42YA 42 Regulation 23(2)(b) Requirement Timescale for action 01/02/06 01/01/06 Repairs and redecoration to the water damaged area of the kitchen ceiling to be again 23(4)(c)(i) For the fire risk assessment to be further developed. 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 YA20YA 20 YA41YA 41 YA42YA 42 Good Practice Recommendations For the signature record to updated of staff approved for administration of medication. For the duty rota to include the actual hours worked by the manager. For a formal system to be instituted for inspection the tumble dryer filter. Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Oakwood Road (56) DS0000013521.V257361.R01.S.doc Version 5.0 Page 27 - 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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