Inspection on 18/09/06 for Oak Close

This inspection was carried out on 18th September 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oak Close 16/09/08

Oak Close 14/03/06

Oak Close 19/05/05

Oak Close 13/12/04

Oak Close 01/10/04

Oak Close 23/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Oak Close 1 - 4 Oak Close Wath-Upon-Dearne Rotherham South Yorkshire S63 7BS Lead Inspector Sarah Powell Key Unannounced Inspection 18th September 2006 10:00 Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 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 Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oak Close Address 1 - 4 Oak Close Wath-Upon-Dearne Rotherham South Yorkshire S63 7BS 01709 760686 01709 877460 susan.case@rotherhampct.nhs.co.uk 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) South Yorkshire Housing Association Limited Mrs Susan Anne Case Care Home 17 Category(ies) of Learning disability (17) registration, with number of places Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A condition of registration allows people over the age of 65 years who have a learning disability to reside at the home. A further condition should restrict the number of people with mobility difficulties to rooms in house one or on the ground floor in house two. 14th March 2006 Date of last inspection Brief Description of the Service: 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 semidetached, with living space for five service users. One of the detached houses provides nursing care. Oak Close is situated on the outskirts of Wath a small town North of Rotherham; facilities nearby include shops, restaurants, leisure activities and a day centre. The fees at oak close range from £304.82 to £385.61 per week. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first key inspection in the year 2005/06 it was unannounced and took place over one day on 18thSeptember 2006 it commenced at 10:00 and finished at 14:30. As part of the inspection process the inspector spoke to 3 Service users, 4 staff and the person in charge the manager was on leave. Two questionnaires from service users were returned. A partial tour of the building took place, observing staff and practices. A number of records were examined these included three service users care plans, menus, recruitment, training records and quality assurance systems. Feedback was given to the person in charge when the visit was completed. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The assessments were in place apart from one, which was a new service user but had been residing at the home for a few months and should have been addressed. EVIDENCE: All service users had a full assessment of needs in their plans of care, which were comprehensive and clearly detailed the needs of the service users. The new service user had an assessment but it was out of date as it was carried out at her old home and had not been reviewed since she had moved into oak Close, which, was in May 2006. This was discussed with the person on duty and it was agreed this would be carried out. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The care plans identified service users needs and how they should be met. EVIDENCE: All service users have a plan of care, which includes how the home will meet their current and changing needs. Two service users were case tracked, as part of the inspection process and the plans in general were very good, identified needs and how these could be met it described and restrictions due to conditions and the plans were regularly reviewed. One service users had recently moved to the home and their plan was still being reviewed and updated this should have been completed as the service users had been at the home for over four months. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 9 Staff provide service users with support they needs to make decisions within their capabilities and this was documented in the plans of care. Risk assessments were well documented in the plans and service users were able to take responsible risks as part of an independent lifestyle, this was evident from talking to staff and observing the service users on the day of the visit. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Independence and freedom of movement is promoted and community links maintained with regular contact with family and friends. EVIDENCE: The service users at Oak Close are unable to take up jobs or educational opportunities due to the degree of their learning disabilities however they all have the choice to attend appropriate day centres and staff support service users to participate in the local community using the local facilities including shops, hairdressers and pubs so that service users are part of the local community. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 11 The home as a vehicle for staff to drive to enable service users to access the local community and have regular outings and trips. This currently is hardly used due to lack of staff able to drive the vehicle. The Manager is currently reviewing this and a suitable solution will be implemented to ensure service users are still able to have transport at the home. Staff support service users to have relationships with family and friends many service users have regular contact with family and friends. Staff spoken to were aware that relationships had to be appropriate to protect service users as due to their learning disabilities not all service users are able to make an informed decision. Staff spoken to said the service users independence is promoted with individuals given choice and freedom of movement and service users rights are respected. This is detailed in individual care plans with relevant risk assessments to meet service users needs. One service users who had recently moved to Oak Close had ceased going to her day care placement following the move this needs to be reviewed. After speaking to the learning disability nurse at the day centre it was ascertained the placement was stopped due to the deterioration in her condition the day care could no longer meet her needs. It is therefore necessary to review her needs regarding recreational and social requirements. All service users are offered a healthy diet, each house does its own shopping with service users if they wish. There are menus drawn up with service user involvement if they are able and choices are always available. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Personal support is given in a way service users prefer, and health care needs are met including medication. EVIDENCE: It was evident from the plans of care and talking to staff that service users health is monitored and potential complications and problems are identified and dealt with at an early stage to prevent further problems. Staff seek help and advice from various health care professionals this was documented in the plans of care in order to meet the needs of service users. Personal support was given sensitively it was flexible maintaining privacy, dignity and independence; this was evident during the inspection. Service users choices were very evident in the way they were dressed in appropriate clothes for their age wearing jewellery and makeup, which reflected their personality. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 13 The person in charge at the time of the visit told the Inspector medication policies and procedures have not changed since the previous inspection. They were assessed as very good at the last visit following a thorough inspection to ensure service users are protected. Medication was not looked at in detail at this visit. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service Service users are protected from abuse and there is a clear and effective complaints procedure. EVIDENCE: The home has a clear and accessible complaints procedure in easy to read format for the service users. The home has received no complaints since the last inspection. The home sends out a newsletter every three month to all relatives and this contains a copy of the complaints procedure so relatives are aware of the procedure and know their views will be listened to and acted on. The home has an adult protection policy all staff are aware of the procedure to follow should an allegation be made. All staff have also attended training on protection of vulnerable adults in order to be aware of different types of abuse and protect service users. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is adequate although the toilet and bathing facilities in house one are Poor as they do not meet service users needs. This judgement has been made from evidence gathered both during and before the visit to this service. The home was clean, homely and comfortable. Sufficient toilets and bathrooms were provided although one bathroom did not meet the needs of the service users and the hoist in one bathroom needs reviewing. EVIDENCE: A partial tour of the building took place the standard of cleanliness observed was very good and the home was maintained to a high standard of décor. In house 1 the toilet used for service users when they are in the lounge is not large enough for use with service users who use a wheelchair and staff are struggling to manage. Two of the service users use a wheelchair at all times and others on occasions. This needs to be reviewed so that the home can meet the changing needs of the service users. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 16 The upstairs bathroom is suitable for service users who use a wheelchair and it also has a bath hoist however this is manual and a mechanical hoist would be beneficial as staff stated it is quite difficult to use to due to the height of the lever and does cause health and safety problems, this should be risk assessed and reviewed to prevent injury to staff and service users. These issues were discussed with Linda Jarrold, Quality Manager, SYHA and an assessment by an occupational therapist is to be carried out. The downstairs bathroom will be reviewed with regard to installing a walk in shower removing the bath to give more room to access the toilet with wheelchair users. The assessment of the manual hoist in the upstairs bathroom will be carried out and look at providing a mechanical hoist. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home has an effective recruitment process and staff are competent and qualified although training records are still being updated. EVIDENCE: A selection of staff personal files were checked these contained all the relevant information ensuring a robust recruitment process to protect service users. Staff training files were in the process of being improved following the last inspection, as this was a requirement the files are to be completed by January 2007. The person in charge at the time of the inspection told the inspector all staff training was up to date it was just a case of completing all the individual files. The home has over 50 of staff trained to at least NVQ level 2 and many staff are also doing NVQ level 3. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is well run with most health and safety promoted and maintained, although PAT testing needs to be updated and a health and safety assessment of the bath hoist. EVIDENCE: The Manager is qualified and competent to run the home she has complete her Registered Managers and has been a registered manager for a number of years with many years experience in this field of work. The home has got good quality monitoring systems based on seeking views of service users and Regulation 26 visits are carried out and the Tenant Participation Officer visits regularly to ensure service users views underpin development in the home. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 19 The home has a good health and safety policy and staff have received health and safety training. The maintenance records for electrical safety, legionella, fire checks and safe environment including equipment and machinery were all up to date however the Pat testing was out of date and it was not clear if the company had been to carry out the testing this needs to be carried out. A health and safety assessment also needs to be carried out on the bath hoist in house one (see standard 24 environment). Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 20 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA2 YA27 Regulation 15 23 Requirement Ensure the care plan and assessment for the new service user is updated. The bathing and toilet needs of service users in house one must be reviewed again to ensure service users individual and collective needs are met. (Old timescale 01/08/06) Ensure all staff training records are completed and all training is up to date. (Old timescale 01/06/06) Carry out a health and safety assessment of the bath hoist in house one. Timescale for action 01/11/06 01/01/07 3. YA35 18 31/01/07 4. YA42 12 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA14 Good Practice Recommendations It is recommended the arrangement regarding a vehicle at the home are reviewed to ensure service users can DS0000003118.V301963.R01.S.doc Version 5.2 Page 22 Oak Close 2. YA12 maintain access to the local community. It is recommended the social and recreational needs of the new service users are reviewed and appropriate activities provided. Oak Close DS0000003118.V301963.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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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