Inspection on 08/06/05 for New Oaks

This inspection was carried out on 8th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

New Oaks 05/01/07

New Oaks 20/12/05

New Oaks 08/02/05

New Oaks 16/09/04

New Oaks 30/03/04

New Oaks 13/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 New Oaks 277 Lordswood Road Harborne Birmingham B17 8QL Lead Inspector Brian Reamsbottom Unannounced 8th June 2005 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. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service New Oaks Address 277 Lordswood Road Harborne Birmingham B17 8QL 0121 250 2502 0121 250 2503 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) New Outlook Housing Ms Michelle louise Dennehy Care Home 6 Category(ies) of Care Home registration, with number of places New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 8/02/05 Brief Description of the Service: New Oaks is a large detached property, for younger adults with a visual impairment and associated learning disability. The home is located on Lordswood Road in Harborne, South Birmingham. The home is a converted traditional property. There are six bedrooms, one with en suite. There are two bedrooms on the ground floor and four are on the first floor. There are two bathrooms, one on each level, one has bathing facilities and one has a shower facility. There is no lift so there would be limitations in the home for people with mobility problems.There is a large lounge with combined dining area and a kitchen and laundry; a lean-to provides extra storage facilities.Staff facilities include an office, shower room and toilet.To the front of the home there is a tarmac drive with on and off entrances and some parking spaces. To the rear of the home there is a large pleasant garden with large patio area, grass and well stocked borders. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected unannounced from 10.40 to 15.00. The documentation inspected included the following: Care plans, risk assessments, fire records, medication records, health and safety records, accident book, daily records, complaints and adult protection records, staff personal files and staff training records. Three service users and two members of staff were spoken with. What the service does well: What has improved since the last inspection? What they could do better: The food eaten by service users must be recorded in enough detail to show that a well balanced diet is being given. There must be enough staff on duty at all times who are qualified and competent to ensure the needs of service users are being met. A quality assurance tool must be put in place. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 6 All records must be signed using surnames and the full date when the record was made. 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. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2 Information is available to enable prospective users make an informed choice as to whether they want to live at the home. EVIDENCE: Service users have access to a summary of the Statement of Purpose and each service user has a copy of the Service User Guide that includes their views. The service users are a stable group and there have been no admissions in the last year. The two service users files sampled had a full assessment done to include the views of service users. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 9 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 8 and 9 Care planning and risk assessment practices meet the needs of the service users living in the home. EVIDENCE: Service users have a care plan, the plans are reviewed every six months or as the needs of service users change. In the plans sampled the words ‘needs assistance’ are being used, for example, needs assistance with dressing. The plans must clearly state what assistance is required. The plans included the wishes, likes and dislikes of service users. The two staff members spoken with said that they are involved in the review of the plans as are social workers and other professionals. Risk assessments have been done for each service user to include their views, and are up to date. On speaking to a service user about risk taking he said that he was involved in his risk assessment and felt well supported by the staff. He was observed making a hot drink independently. Service users have a say in the running of the home through their own weekly meetings. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 10 Service users comments and views made at the meetings are recorded. Staff members were observed asking the views of service users what they wished to do during the day. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 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 standard(s) 12 13 14 and 17 Service users have access to a range of opportunities to afford them a meaningful lifestyle. A nutritious and varied menu is provided to meet individual dietary requirements. EVIDENCE: Service users have weekly sheets showing the activities in the home and away from the home, for example, swimming, horse riding, massage, and aromatherapy. Service users were going for a swimming session. A service user made it known that she did not want to go swimming. The staff respected her wish. Service users have had a holiday in South Wales, A service user said that he enjoyed the holiday. Service users access local shops, cinema, social clubs and library. Visits are made to the local pub for a drink and a meal. Service users have good contact with their families, by visits, letters, cards and telephone calls. The manager and staff are actively involved in maintaining links with service users and family. Records of contact with families are kept in the service users personal files. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 12 The menus showed that the food is varied, wholesome and nutritious. Records are kept of the actual food eaten by service users. These records need more detail, for example, meat pie and vegetables, the vegetables eaten must be recorded to ensure service users are getting a balanced meal. Service users take part in the shopping for food at local shops and the supermarket. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 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 standard(s) 18 19 and 20 The medication management is good ensuring service users receive medication as prescribed. Systems are in place to ensure that service users receive the care they need. EVIDENCE: The two care plans inspected showed that personal care is given daily in a manner liked by service users. Personal care is given behind closed doors, in toilets, bathrooms and bedrooms. Service users have their own routines that they follow and are respected by the staff group. Service users choose their own clothing that they wish to wear from their wardrobes. Service users healthcare is being met. Visits to GPs, Opticians and Dentists are made. Service users are referred to other professionals as required, for example, Psychologists, Psychiatrists and Dieticians. Community Nurses and Chiropodists visit when needed. The home is working on introducing Health Action Plans for each service user. They are looking at the best way to include the involvement of service users in their Health Action Plan. None of the service users are able of administering their own medication. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 14 The management of medication is good. A Monitored Dosage System (MDS) is in place. There are protocols for ‘as required’ (PRN) medication. A Pharmacist from the supplier of the MDS visits the home on a regular basis giving support in the safe administration and storage of medicines. Medication is safely stored in an appropriate cabinet. The manager is keeping copies of prescriptions, however, the wrong part of the prescription is being kept. The part to be kept is the one showing what medication the GP has ordered and signed by them. The staff team have received accredited medication training. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 15 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 and 23 The complaints and adult protection procedures available ensure that service users are protected from harm. EVIDENCE: The and The and home has a complaints procedure in place it is also available in large print audiotape, this is to be commended. complaint procedure inspection must have the NCSC changed to the CSCI have the address of the Ombudsman. The manager states that they have received no complaints since the last inspection. The adult protection procedures in place reflect the spirit of Birmingham’s Multi-Agency Guidelines. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 16 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 25 and 30 The home was clean, warm and fit for its purpose and provides service users with a safe, homely and comfortable environment. EVIDENCE: The home was clean, warm and hygienic. It is decorated and furnished and maintained to a high standard. It was comfortable, relaxing and a pleasant environment. A full tour of the home was not done. The two bedrooms inspected were well decorated and furnished. There were items around the rooms reflecting the personalities of the individual service user. Policies and procedures for the control of infection are in place they include dealing with spillages, the provision of protective clothing and hand washing. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 17 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 34 and 35 The homes recruitment procedure is robust and ensures that service users are protected from harm Staff have received training to meet the needs of service users. EVIDENCE: At the start of the inspection there were three service users in the home being supported by a member of staff and a volunteer. The inspector asked who was on duty, the staff member stated that the deputy manager and a member of staff had gone with a service user to get a bus pass and to take a service user to day care. Two other members of staff had gone to Boots to buy items for sun screening. When the deputy manager returned he was asked about the staffing levels. He said that he was not aware that two members of staff had gone out of the home. It was explained to the deputy manager that a volunteer is not a replacement for a member of staff. There must be sufficient qualified and competent staff on duty to meet the needs of service users at all times. The staff files inspected included all the information and documentation required in Schedule 2 of the Regulations. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 18 The organisation is committed to having well trained staff. The staff team have completed the Learning Disability Award Framework (LDAF) training. NVQ levels 2 and 3 training has been done. A member of staff that has recently completed NVQ level 3 training said that she found the training beneficial enabling her to meet the needs of service users. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 19 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 41 and 42 The home is well managed and promotes the health and safety of service users. EVIDENCE: New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 20 The home is involved in producing a quality assurance monitoring system to include the views of service users, family, friends and involved professionals. There is an annual development plan for the business available if required. In the service users files inspected members of staff are not including their surnames when signing records and reports. The person making the records must use surnames to state that they are responsible for the records. In one of the files inspected there was a loose record of hospital appointments, there was two entries dated 22.3 it was difficult to know what year the appointments took place. The year must be added to the date, for example, 23.03.05. The home has a range of policies, procedures and systems in place to comply with the requirements of health and safety legislation. Risk assessments are in place for the premises, fire, food, hygiene and service users. Records of testing of electrical, fire and gas equipment were seen to be in order. Water and fridge/freezer temperatures are tested on a regular basis and a record kept. New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 21 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 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 2 Standard No 31 32 33 34 35 36 Score x 2 x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 New Oaks Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x 2 3 x e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 22 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 YA 17 Regulation 16.(2)(i) Schedule 4 (13) Requirement Records of food provided for service users must be in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactiory. Copies of prescriptions must be kept Ensure that at all times suitably qualified, competent and experienced person are working at the care home in such numbers as are appropriate for the health and welfare of service users. The manager must be qualified to NVQ level 4 in management and care. There is a continuous self monitoring, using an objective, consistently obtained and reviewed and variable method and involving service users and an internal audit takes place at least annually. All records must include the surname of the person making the record and the full date must be included Timescale for action 09.06.05 2. 3. YA 20 YA 32 13.(2) 18.(1)(a) 30.06.05 08.06.05 4. 5. YA 37 YA 39 9.(2)(i) 24.(1)(a) (b)(2)(3) 31.12.05 30.09.05 6. YA41 17.(1)(2) 09.06.05 New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations New Oaks e54_S16805_NewOaks_V231613_080605 - Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ 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. 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