Inspection on 13/12/04 for Oak Close

Care Homes For Adults (18 ­ 65)Oak Close1 - 4 Oak Close Wath-Upon-Dearne Rotherham South Yorkshire S63 7BSUnannounced Inspection13th December 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Oak Close Address Oak Close, 1 - 4 Oak Close, Wath-Upon-Dearne, Rotherham, South Yorkshire, S63 7BS Email address Tel No: 01709 760686 Fax No: 01709 877460Name of registered provider(s)/company (if applicable) South Yorkshire Housing Association Limited Name of registered manager (if applicable) Mrs Susan Anne Case Type of registration Care Home No. of places registered (if applicable) 17Category(ies) of registration, with (number of places) Learning disability (17) Registration number C070000197 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 10th February 2003 yes YES 1.10.04 If Yes refer to Part COak ClosePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 313th December 2004 12.30hrs Sarah PowellID Code107246Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionOak ClosePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementOak ClosePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Oak Close. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Oak ClosePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Oak Close is a care home for younger adults with learning disabilities. The home can accommodate 17 service users. There are four houses in total, two are detached and accommodate six service users in each and two linked semi-detached, with living space for five service users. One of the detached houses provides nursing care.Oak ClosePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This is the second inspection in the year 2004/2005 and as such following the latest guidance from CSCI will address the requirements and recommendations from the last inspection and any key standards that were not covered at the previous inspection. Choice of Home (Standards 1-5) The 1 standard assessed was not met. At the last inspection the statement of purpose and service users guide required a few small amendments. The Acting Manager and staff have updated these to incorporate all the requirements, the new packs had arrived from South Yorkshire Housing and these were seen by the inspector. There was a sheet in these packs for the service users/relatives to sigh to confirm they had received the updated copy. The Registered Nurse on duty told the inspector that she expected all the forms to be signed by the end of March, if by then relatives had not visited then Key workers would go through the information with the service users. Individual Needs and Choices (Standards 6-10) None of these standards were assessed. Lifestyles (Standards 11-17) The 2 standards assessed were met. Some service users attend day centres where they can learn practical life and social skills, with the opportunity of improving their social and emotional behaviours as they mix with others outside of the home. Observation of the home and its routines indicated that the care given is dictated by the wishes of the individuals and is flexible to enable their choices to be carried out wherever possible. The home has a policy on smoking; however this needs to be developed to include information about the use of alcohol and drugs. The registered person should ensure the policy is included in the statement of terms and conditions/contract. South Yorkshire Housing Associations new policy and procedure group were currently developing this. Meals are cooked individually in each house. Set menus have been developed they had been drawn up in conjunction with the dietician and were well thought out, nutritious and met the requirements of the service users likes and dislikes.Personal and Healthcare Support (Standards 18-21) Oak Close Page 6 None of these standards were assessed.Concerns, Complaints and Protection (Standards 22-23) The 1 standard assessed was met. No progress has been made towards accessing physical intervention training for the staff. This has been a requirement in the past three inspection reports and must be addressed by the registered person. Evidence indicates that the home has comprehensive policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of service users money and financial affairs and Staff displayed a good understanding of the vulnerable adults procedure. They were confident about reporting any concerns and certain that any allegations would be followed up promptly and the correct action taken. Since 4.10.04 all new staff are only appointed following a satisfactory POVA check. Environment (Standards 24-30) The 1 standard assessed was not met. House 1 accommodates the service users with nursing needs, over the last twelve months two of the service users needs have increased and the toilet and bathing facilities do not meet their needs. The house has a very small bathroom, which is difficult to access by the service users in wheelchairs. The facilities should be reviewed and the necessary facilities provided to meet the needs of service users. It was also recommended by the inspector that the registered person should seek advice from an Occupational Therapist as to the facilities required and about the different ways in which this bathing and toilet facilities could be improved. Staffing (Standards 31-36) 2 of the 3 standards assessed were met. 8 Nursing Assistants have completed NVQ level 3 and three are due to finish in January this still does not meet the requirement of 50 the manager is aware that a target of 50 should be achieved by 2005. At the last inspection examination of the recruitment policy and procedure indicated that this needs up dating to include the POVA guidance issued by the department of health on July 26th 2004, regarding the need to complete a POVA check as well as a CRB check for all new members of staff before they start work. The NHS Trust has now implemented this. Conduct and Management of the Home (Standards 37-43) 2 of the 4 standards assessed were met. Evidence indicates that the registered manager has worked hard to ensure records required by regulation are up to date and accurate, although the statement of purpose and service user guide require some amendments completing.Oak ClosePage 7 Service users/representatives who spoke to the inspector were aware they could access their personal records on request and information about how to do this was seen in the policy and procedure file. Inspection of the home indicated that all records are kept safe and secure and used in accordance with the Data Protection Act 1998.Requirements from last Inspection visit fully actioned?NOCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Named service users over the age of 65 are able to stay at Oak Close. If the service users should leave this condition will be removed.MET (YES/NO)YESOak ClosePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1.6.04 old timescale 31.3.05 new timescale 1.1.05 old timescale 31.3.05 new timescale 31.3.05112YA23The manager must ensure that staff, receive training on the use of physical intervention.24,5,6,7,16YA1 YA41The registered person must ensure the statement of purpose and service users guide is amended to meet the requirements of this standard. The registered provider must ensure the bathing and toilet needs of service users are met in house 1.316YA27Oak ClosePage 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * It is recommended that NHS staff are subject to a three month probationary period when working in a South Yorkshire Housing Association establishment. The registered person should ensure the policy on smoking, drugs and alcohol is developed and is included in the statement of terms and conditions/contract. The home should have 50 of care staff with an NVQ 2 by 2005. The registered manager should achieve an NVQ 4 in management by 2005 (or equivalent qualification). The registered person should ensure policies and procedures are reviewed and up dated in line with current legislation and practice.1YA342 3 4 5YA16 YA32 YA37 YA40* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Oak ClosePage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES NO NO NO NO YES YES YES YES YES YES NO NO NO YES NO YES 3 0 0 NO YES YES YES 29 X 13/12/04 12.30 4Oak ClosePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Oak ClosePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 294.43 372.46 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Key findings/EvidenceStandard met?2Evidence was seen of the statement of purpose and service user guide within the service users information pack. At the last inspection the statement of purpose and service users guide required a few small amendments. The Acting Manager and staff have updated these to incorporate most of the requirements although some policies are currently being updated and when completed will be added to the packs, the new packs had arrived from South Yorkshire Housing and these were seen by the inspector. There was a sheet in these packs for the service users/relatives to sigh to confirm they had received the updated copy. The Registered Nurse on duty told the inspector that she expected all the forms to be signed by the end of March, if by then relatives had not visited then Key workers would go through the information with the service users.Oak ClosePage 13 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? Not assessed at this inspectionStandard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? Not assessed at this inspectionStandard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? Not assessed at this inspectionStandard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? Not assessed at this inspectionOak ClosePage 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 0 Key findings/Evidence Standard met? Not assessed at this inspectionStandard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? Not assessed at this inspectionOak ClosePage 15 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? Not assessed at this inspectionStandard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? Not assessed at this inspectionStandard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? Not assessed at this inspectionOak ClosePage 16 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? Not assessed at this inspectionStandard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? Not assessed at this inspectionOak ClosePage 17 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? Not assessed at this inspectionStandard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? Not assessed at this inspection0Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Not assessed at this inspectionOak ClosePage 18 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Discussion with the staff indicated they are aware of the importance of maintaining the privacy and dignity of the service users, and used this knowledge to back up their practice. During the inspection staff were seen to knock on doors before entering and call service users by their preferred form of address. The inspector found the staff to be friendly; confident in their abilities and skills, and use of effective communication means they have a good relationship with the service users. Discussion with the staff nurse indicated that service user rooms are respected as private spaces, service users can spend time alone in their rooms or access the communal space. Each service user has a lock on their bedroom door and is able to use this if they wish. The home has a policy on smoking; however this needs to be developed to include information about the use of alcohol and drugs. The registered person should ensure the policy is included in the statement of terms and conditions/contract. South Yorkshire Housing Associations new policy and procedure group were currently developing this. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Meals are cooked individually in each house. Set menus have been developed they had been drawn up in conjunction with the dietician and were well thought out and met the requirements of the service users likes and dislikes.Oak ClosePage 19 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? Not assessed at this inspectionStandard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence Not assessed at this inspection Standard met? XX 0Oak ClosePage 20 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? Not assessed at this inspectionStandard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? Not assessed at this inspectionOak ClosePage 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence Not assessed at this inspection X X X X X X X Standard met? 0Oak ClosePage 22 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists Key findings/Evidence YES0 Standard met? 3No progress has been made towards accessing physical intervention training for the staff. This has been a requirement in the past three inspection reports and must be addressed by the registered person. Evidence indicates that the home has comprehensive policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of service users money and financial affairs and Staff displayed a good understanding of the vulnerable adults procedure. They were confident about reporting any concerns and certain that any allegations would be followed up promptly and the correct action taken. Since 4.10.04 all new staff are only appointed following a satisfactory POVA check.Oak ClosePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? Not assessed at this inspectionOak ClosePage 24 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence Not assessed at this inspection YES NO NO X X X X Standard met? 0 X XX X X XOak ClosePage 25 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence Not assessed at this inspection. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 2 Key findings/Evidence Standard met? House 1 accommodates the service users with nursing needs, over the last twelve months two of the service users needs have increased and the toilet and bathing facilities do not meet their needs. The house has a very small bathroom, which is difficult to access by the service users in wheelchairs. The facilities should be reviewed and the necessary facilities provided to meet the needs of service users. It was also recommended by the inspector that the registered person should seek advice from an Occupational Therapist as to the facilities required and about the different ways in which this bathing and toilet facilities could be improved. Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? Not assessed at this inspectionOak ClosePage 26 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? Not assessed at this inspectionStandard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? Not assessed at this inspectionOak ClosePage 27 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? Not assessed at this inspectionStandard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 2 Key findings/Evidence Standard met? 8 Nursing Assistants have completed NVQ level 3 and three are due to finish in January this still does not meet the requirement of 50 the manager is aware that a target of 50 should be achieved by 2005. Observation of the staff at work showed they communicate well with the service users and offer support and assistance in a friendly and relaxed manner. Discussion with staff showed them to be motivated and enthusiastic about their work and committed to achieving high standards of care.Oak ClosePage 28 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme Key findings/Evidence Not assessed at this inspection X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXXStandard met?0Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. Key findings/Evidence Standard met? 3Evidence indicates no progress has been made towards ensuring new staff, are employed on a three month trial basis. This is an outstanding requirement from previous inspections. At the last inspection examination of the recruitment policy and procedure indicated that this needs up dating to include the POVA guidance issued by the department of health on July 26th 2004, regarding the need to complete a POVA check as well as a CRB check for all new members of staff before they start work. The NHS Trust has now implemented this.Oak ClosePage 29 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? Inspection of the files showed that staff, receive induction and foundation training, this is linked to meet the national training organisation (NTO) workforce targets and Sector Skills Council specification.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? Not assessed at this inspection0Oak ClosePage 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. Key findings/Evidence NO 2Standard met?Information given to the inspector by the manager indicates she is a registered nurse (MH) with experience and skills in caring for service users with learning disabilities. She is in the process of completing her NVQ 5 in operational management. The manager has a job description, which covers all aspects of her role and responsibilities.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not assessed at this inspectionOak ClosePage 31 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? There are regular staff meeting. There are also service users meeting. The registered provider carries out regulation 26 visits monthly. The manager carries out regular audits. There are regular resident satisfaction questionnaires carried out. The home has an annual development plan this was seen by the inspector and was comprehensive. Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 2 Key findings/Evidence Standard met? Evidence indicates that the home has a wide range of policies and procedures, which are discussed with the service users and staff. A number of these require reviewing Rotherham Primary Care Trust has set up a new policy and procedure group who are currently looking at all the policies and are reviewing and updating the necessary policies.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met ? Evidence indicates that the registered manager has worked hard to ensure records required by regulation are up to date and accurate, although the statement of purpose and service user guide require some amendments completing. (see standard 1) Service users/representatives are able to access their personal records on request and information about how to do this was seen in the policy and procedure file. Inspection of the home indicated that all records are kept safe and secure and used in accordance with the Data Protection Act 1998.Oak ClosePage 32 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? Not assessed at this inspectionStandard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? Not assessed at this inspectionOak ClosePage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceRegulatory Inspector Second Inspector Regulation Manager DateSarah Powell Ann MicklethwaiteSignature Signature SignaturePublic reports It should be noted that all CSCI inspection reports are public documents.Oak ClosePage 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 13th December 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleWe are working on the best way to include provider responses in the published report. In the meantime responses are available on request.Action taken by the CSCI in response to provider comments: Oak Close Page 35 Amendments to the report were necessaryYESComments were received from the providerYESFactual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOOak ClosePage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, Ms Jillian Meek of Oak Close, confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the 13th December 2004 and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I, Ms Jillian Meek of Oak Close, am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the 13th December 2004 for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Oak ClosePage 37 Oak Close / 13th December 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000003118.V147508.R01© This report may only be used in its entirety. 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