CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65
Coombe Oak Warren Road Kingston Upon Thames Surrey KT2 7HY Lead Inspector
Michael Stapley Unannounced Inspection 12th December 2005 09:30 Coombe Oak DS0000013382.V272497.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 Coombe Oak DS0000013382.V272497.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 Older People and 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. Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Coombe Oak Address Warren Road Kingston Upon Thames Surrey KT2 7HY 020 8547 3777 0208 974 5801 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) Welmede Housing Association Ltd Ms Lorraine Laporte Care Home 22 Category(ies) of Learning disability over 65 years of age (21) registration, with number of places Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Room 2, House 3 may be provided with a suitable alternative floor covering in place of carpet. To be reviewed at least annually. 9TH August 2005. Date of last inspection Brief Description of the Service: Coombe Oak is a residential care home providing care for twenty-two service users with learning disabilities. Care is provided in four separate houses on one site. Each house provides ground floor accommodation for service users. The Royal Borough of Kingston upon Thames own the home and it is managed by Welmede Housing Association Limited on a contract basis. The home is located a quarter of a mile from local shops and other ammenties. Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This home was inspected under the National Minimum Standards for Care Homes for Younger Adults. The inspection took place over one day on 12th December 2005. The management structure of the home has been resolved albeit on a temporary basis. One of the housing association’s service managers who has been supporting Coombe Oak for over fifteen months has submitted an application to the commission to be the registered manager of the home. Although this application is welcome the housing association is also going through the process of change which will lead to a new regional management structure which could affect the management of Coombe Oak. However Coombe Oak is a ‘core and cluster’ home with four houses on the campus. Each house is managed by a house manager with an independent staff team and they all offer a quite different and unique service. However all the houses operate under the policies and procedures of Welmede Housing Association. The current manager of Coombe Oak is very experienced and well qualified. He has reviewed and updated many of the homes policies and procedures and introduced many new working concepts for the benefit and well being of the service user’s at the home. Records examined during the inspection year 2005-06 included service user plans; care manager needs assessments and risk assessments, medication records, complaints, staffing records, health and safety and fire records. Previous requirements and recommendations were discussed with the manager of the home and they were all found to have been met. What the service does well:
Service users are very much the centre of attention in the home, service users have been very complimentary about staff and have been generally happy with how the home is being run, service users have also commented positively about activities, food and their opportunities to be involved in running the home during the two inspections of 2005-06. During the course of the inspection it was evident that the home had worked exceptionally well with one particular service user. It was clear that this service user could and should be in her own accommodation with floating support. She is very independent, organizes her own finance and transport arrangements. The home is very supportive of this service user gaining her own
Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 6 accommodation and it is to be hoped that the local authority can find suitable accommodation in the locality shortly. Individual care plans are very comprehensive and headings include a pen portrait of the service user, weekly activities, health needs and communication skills to mention a few. The arrangements for health care needs of the service users is good, all service users are registered with a local General Practitioner, the home has the support of a local pharmacist for advice on medication. Staff members have access to a range of training courses to build on their skills to ensure that they are able to meet the service users assessed needs, although the NVQ element of this programme of needs to be developed further. The home holds the “Investor in People” award and has meet all of the requirements from the last CSCI inspection. What has improved since the last inspection?
The new manager and senior staff are continuing to use staff meetings at the home as a tool to improve communication amongst the team and discuss basic care values. Staff members have improved their skills and knowledge by attending a number of training courses. Care plans have been reviewed in consultation with service users and they now contain all elements of standard six. In addition Person Centred care plans have been introduced for all service users and staff has received appropriate training in order to facilitate such plans. The home has a complaints procedure both in written and pictorial form. There have been improvements in the environment with refurbishment and redecoration having taken place. The managing company has improved its systems of communication and there are good support mechanisms within the organization. Staffing at the home has been improved and this has strengthened the ability of the home to offer more individual work with service users. In addition the current manager has introduced Team Building for each House which has proved very effective. The home has embraced the Health and Safety Executive’s HSE Standards for Stress Awareness by introducing the later as part of its core training. All house managers and senior staff have undertaken Risk Assessment training and a stress audit has been introduced. These changes combined with the homes service development plan has significantly added to the positive work that is currently taking place at Coombe Oak. Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 7 What they could do better: All of the previous requirements have now been met and there was only one requirement from this inspection. While the day to day management of the home has been resolved Welmede Housing Association still need to address the management of each individual house. Each of the four houses on the site is managed separately with a distinct client group and a Statement of Purpose that differs from house to house. The manager of each house is not registered with the Commission Social Care Inspection and the managing authority should give due consideration to registering each of the homes managers. In addition consideration should be given to which category each house is registered given that one house accommodates service users who are all over sixty five years of age. If each house were registered on an individual basis with a registered manager then each house would be inspected individually under the appropriate category. At present all of the four houses are inspected under the ‘Younger Adults’ category with exemptions in place for those service users who are over sixty five years old. In addition although staff records were now available at the home it is suggested they be filed in a clear and logical manner with a front sheet indicating what documents were available for ease of reference. While the staff training programme is excellent the number of staff who have achieved an NVQ at level 2 or above does not meet the 50 the home is required to achieve by the end of 2005. While it is acknowledged that there have been local difficulties in finding a suitable provider of NVQ training the home must submit an ‘action plan’ indicating how they intend to meet this standard. All of the staff have undertaken Fire Awareness Training which is seen as a high priority by the home. It was therefore somewhat disappointing to note that the Fire Risk Assessment had not been reviewed since August 2004. The manager of the home advised this would be reviewed as a matter of priority. While staffing at the home has been increased it was noted in House 4 that there had been major changes. The manager of the house was relatively new in post as were the majority of staff. The manager of the house stated “that she had a team but now had to build it” Clearly team building is of utmost importance in this particular house. It was further noted that some staff who were still on probation were supporting those staff who had recently commenced duties at the home. This had inadvertently caused some
Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 8 difficulties for the house and the manager. While it is acknowledged that the home needs an effective staff team it is suggested that new staff commence their duties in a phased manner rather than introducing many new faces to service users all at once. 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. Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 The home provides good information and introduction opportunities for prospective service users to make an informed choice about moving to the home. Contracts between the home and the service users contain all the information required under standard five thus ensuring the rights of the residents of Coombe Oak. Staff at the home have access to a wide range of training programmes thus enabling them to offer an effective care programme for service users. EVIDENCE: Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 11 The home has a preadmission procedure; prospective service users are able to visit the home on an individual basis. Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. All of the service users at Coombe Oak have such an assessment and it was evident in discussion with the homes manager that assessment is on going and is seen as very much part of the care plan. Personal Care plans are based on an in depth assessment of all aspects of service users personal care, social, recreational and emotional needs. The home carries out internal three monthly reviews where information is up dated and care plans changed as appropriate. There are also yearly reviews carried out with the service users, their families and other professionals as appropriate. The home has an excellent training programme including NVQ training, although the later requires further development. The managing company is also an “Investor in People” The training programme includes epilepsy, medication, working with symbols, makaton training. All staff have a training plan and the homes manager has introduced team building for each house. This has proved very effective and is being used as a tool to effect change and help develop the service Contracts between the home and the service users were evidenced and although these are licence agreements they contain all the information as required under standard 5.2. Of the two outstanding requirements it was noted that the Statement of Purpose has now been updated for each house and, in addition the manager has compiled an information leaflet for service users in each house. Communication plans and guidance were now also in place for all service users. Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) 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 and 9. Service user care plans contain all the information required as per standard six. Staff at the home have all the information they require to satisfactorily meet the needs of the service users. Service users have individual risk assessments and risk management strategies carried out thus enabling them to participate in activities in the home and in the community with appropriate support. EVIDENCE: Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 13 Service user individual care plans are comprehensive and contain all the elements of standard six. Care plans contain a pen portrait of the service user, weekly activities, health needs and communication skills. Service users and their respective families are involved in drawing up such plans as outlined in standard 6.6. In addition service users have a key worker; detailed six monthly service user’s reports are written by the key worker and are comprehensive. The home is very service user focused. Service users are encouraged to become far more involved in the home. Service users meetings take place on average six times a year with an external facilitator and a service user’s day took place in September 2005. Such meetings are used as a communication tool to empower service users; minutes of these meetings are available on request. Service users files sampled at random all had individual risk assessments and risk management strategies. Service users are encouraged to make their own decisions within the context of risk assessment wherever possible. All service users have individual choice and the home provides an independent advocate where desired. The home also has an independent advocate who visits the home three or four times each year and spends time in each house. Service users are also involved in the Royal Borough of Kingston-upon-Thames service users ‘Parliament’ In addition service users sit on the housing associations operations committee. Service users are also involved in staff interviews and a recent innovation is that they are now paid to attend these interviews and receive appropriate training. Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 The daily routines and house rules promote residents’ rights and encourage independence. Service users are given opportunities to engage in age appropriate activities with an emphasis on using community based facilities. Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 15 Dietary needs are catered for and a balanced diet is provided, to ensure a nutritious diet based on personal preferences. EVIDENCE: The home supports service users to access appropriate activities through the activity programme. The service users access local parks, cafes, theatres, local leisure facilities and shops. In addition to swimming, gym and library. The staff team are available to support service users while accessing community resources. Service users spoken to stated that they enjoyed the activities on offer at the home. The home had a barbecue for the whole project in September 2005 where family, friends and parents all met in an informal setting. This proved very successful and similar activities are planned for next summer. Service users at the home have an annual holiday; three of them went to Las Vegas while others went to the Isle of Wight, Bognor Regis and Brussels during the course of 2005. In addition the changes implemented in the “floating support review” have meant more focus on individual support and targeting support for the purpose it is intended. Weekly menus were constructed with the aid of the service user’s personal choice, advice from service user’s families and the experiences of the staff. One service user said that she enjoyed what she had to eat at the home. Service users are usually weighed monthly although one service user who is on a ‘Healthy Eating’ programme is weighed weekly. Any concerns are monitored by the dietician. Although the home has its own mini-bus at present they do not intend to renew the lease when it expires. The manager advised that the mini-bus is under used due to lack of drivers. As the cost of running the mini-bus is paid by service users it is often a case of paying for something they do not use. The home, with the agreement of service users will therefore use such resources as Dial a Cab; Dial a Ride and local mobility transport. When the need arises a mini-bus will be hired for particular events. In addition one service user is in the process of purchasing their own car. Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) 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 and 20 Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ medication is well managed to ensure good health. EVIDENCE: Health records are maintained for each service user. Service users records examined during the inspection demonstrate that the service user had access to routine health checks and specialist health care. Significant events and accidents are recorded and monitored. The staff team at the home keep a central record of incidents as well as an individual record on service user’s files. Staff members monitor service user’s health and maintain up to date records. Most of the staff team have undertaken medication training and an in
Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 17 house assessment. The pharmacist from Boots visits the home on a regular basis. The last inspection was on 16th May 2005. The report was evidenced during the course of this inspection and all recommendations and requirements had been complied with. All medication records were correct at the time of the inspection with tubes and tubs clearly stating the date of opening. All service users have a Health Action Plan and Health Action Checklists are compiled for all service users. In addition all staff have undertaken Health Action Planning Training. Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16, 18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 16, 18 and 35 (Older People) 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 and 23. There is a complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: The home has a detailed complaints procedure. A pictorial format of this procedure has been developed and provided to service users. The Homes Manager said that no complaints have been made to the home since the last inspection. There are also policies and procedures in place regarding the protection of vulnerable adults. The homes manager, who is a qualified trainer, stated that the staff team have all completed a refresher course on adult protection issues. The staff team are aware of the action they must take if they need to report an incident. Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 19 Environment
The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 28, 29 and 30. Service user’s bedrooms provide privacy and reflect individual interests and preferences. The home is homely, bright and clean with the necessary adaptations in place, thus providing the service users with safe, comfortable surroundings that meet their needs. EVIDENCE: Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 20 The home is set in spacious grounds situated in a quiet tree lined residential road. It is situated in Kingston upon Thames and is close to local shops and amenities. The complex consists of four separate houses. There is a large communal lounge on the ground floor as well as a spacious kitchen/dining room. The furniture is domestic, flame retardant, and of good quality. There has been some improvements in the décor of the home since the last inspection, the kitchen in house four has been replaced and redecorated. One service user commented the surrounds of one of the kitchen surfaces needed to be curved as opposed to straight edged as one service user had cut himself on the surround. The homes manager agreed to look into this matter. In addition new furnishing, fixtures and fittings are to be purchased as required. There is also a pleasant garden which is well used by the service users in the summer months. Bedrooms viewed provided sufficient and suitable furniture. All areas of the premises viewed were clean and free from offensive odours. There are appropriate laundry facilities although one service user commented that the tumble dryer needed replacement. Systems are in place for controlling the spread of infection. This includes staff training in this area. The home has one ‘high low’ bath situated in one of the houses. The home has thermostatic valves fitted to each of the baths to avoid any scalding accidents. The temperature of the water is taken and recorded on a chart in the office on a weekly basis. Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 21 Staffing
The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34 and 35. There are sufficient staff on duty that collectively have the skills and experience to provide a good level of care for the service users in this home. Robust recruitment procedures and staff training ensure that service users are well cared for. EVIDENCE: Staff turnover in the home is relatively low; many of the staff has been with the home for some years. There is now a good balance of staff. Shifts leaders support each of the house managers while there are an enthusiastic team of carers who have a variety of experience and qualities. Some of them have gained an NVQ level 2 qualification and some are planning further studies. A
Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 22 number of staff files were inspected at random and all those inspected complied with the standard. Copies of their induction programme were seen. No new member of staff is employed until POVA and CRB checks are complete. There is a through training programme in place and staff spoken to confirmed that they had been able to access training. The homes manager is responsible for supervising the house managers while house managers supervise their respective staff. Supervision is in line with the standard. The homes manager advised that staff meetings usually take place every fortnight. They are used as a communication tool, where information is shared and common themes are addressed. Staff meetings minutes evidenced were clear and focused on service users needs. There are a minimum of two or three staff members on duty on each shift depending on the needs of service user’s. Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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 and 42. The home benefits from a strong staff team with good leadership, which ensures a high standard of care. Attention to health and safety procedures means that the wellbeing of service users is maintained. EVIDENCE:
Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 24 The homes manager is well qualified and experienced to manage the service. He is an effective leader who supports his team for the benefit of the service users at the home. He has excellent interpersonal skills and operates in an open and transparent manner. Meetings are held for service users on a regular basis and relatives/friends are always welcome to attend. Staff meetings are held every fortnight and minutes were available for inspection on request. It is suggested that staff sign them to ensure they have read them. Service user’s questionnaires have been drawn up by the manager and this will form the basis of the homes quality assurance system which is shortly to be introduced. Two service users at the home are responsible for their own financial affairs. Maintenance records were seen and were all in good order. Fire safety requirements had all been complied with; save for updating the fire risk assessment, which the manager advised, will be completed shortly. The home has the appropriate insurance policies in place. Kitchen practices were good and all staff have received appropriate health and safety training. The home had an inspection from the Royal Borough of Kingston-upon-Thames Environmental Health Officer on 12th July 2005 and all requirements from that Inspection have been complied with. The homes policies on Food Hygiene have been updated since the Inspection while new Health and Safety policies have been recently introduced. Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 X 4 X 5 3
INDIVIDUAL NEEDS AND CHOICES CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT 37 3 38 X 39 3 40 X 41 X 42 3 43 X Standard No 6 7 8 9 10 LIFESTYLES 11 12 13 14 15 16 17 Score 3 3 X 3 X X 3 3 3 3 3 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA32 Regulation 18 Requirement The registered provider must send to the CSCI, local office an ‘Action Plan’ stating how and when they plan to meet the target of 50 qualified to a minimum of NVQ level 2. Timescale for action 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Coombe Oak DS0000013382.V272497.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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