Inspection on 23/03/04 for Oak Close

Care Homes For Adults (18 ­ 65)Oak Close1 - 4 Oak Close Wath-Upon-Dearne Rotherham South Yorkshire S63 7BSUnannounced Inspection29th March 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 28/7/03 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 329th March 2004 09:00 am Sarah PowellID Code107246Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process 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 Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. 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: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where 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 National Care Standards Commission (NCSC) 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 NCSC in respect of Oak Close. The inspection findings relate to the National Minimum Standards (NMS) for Care Home 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 NCSC 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 · Report of the Lay Assessor (where relevant) · 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 and the Children Act 1989 as amended. 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 two detached, accommodating six service users in each and two linked semi-detached housing 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 2003/2004 and only covers a selection of the standards. All the standards would have been covered at least once over the two inspections. Choice of Home (standards 1 ­ 5) 1 of the 2 standards assessed were met All the service users have lived at Oak Close for many years. All the service users seen by the inspector were very happy. Full assessments are carried out on all service users and preserved rights assessment by social services has been carried out on all service users in the last twelve months. The statement of purpose and service user guides are currently being reviewed and should be completed within three weeks. Individual Needs and Choice (standards 6 ­ 10) All 2 of the standards assessed were met Each service user has an individual plan, this is well detailed and in formats that the service user understands. They are developed with the service user and their families; they were agreed and signed by the service user. The manager stated that staff support service users to make decisions about their lives. Where more specialised information was needed to make a decision, other professionals were involved. Details of their involvement were recorded in personal files. Lifestyle (Standards 11 ­ 17) All 3 of the standards assessed were met Each service user had a timetable of activities. They either attend day services or college on weekdays, although the service users in one house are over the age of 65 and have retired. Daytime activities are arranged for these. The Manager and staff in the home take reasonable steps to ensure that service users rights are respected as far as possible. The home offers a healthy and varied diet to the service users, which ensures that they have choice and the opportunity to be involved in the preparation of meals, and staff confirmed that mealtimes were flexible. Personal and Healthcare support Concerns, (Standards 18 ­ 21) Oak Close Page 6 All 3 of the standards assessed were met All service users have their healthcare needs assessed by a suitably qualified person, and access local community providers as well as specialist services. This was evidenced in the plans of care. The ageing, illness and death of service users is dealt with sensitively and with respect. The manager has recently discussed these issues with the service users and their families to ensure the home is aware of their wishes. Complaints and Protection (Standards 22 ­ 23) 0 of the 2 standards assessed were met There was a clear complaints procedure although this was only displayed in the office. There was an adult protection and whistle blowing policy available and all staff had attended a course on whistle blowing. Environment (Standards 24 ­ 30) 4 of the 5 standards assessed were met The home was well maintained, clean and homely. A large amount of decoration has been carried out since the last inspection. The patio area has been greatly improved and is safe and accessible to all service users. All the necessary adaptations are installed. Staffing (Standards 31 ­ 36) 3 of the 5 standards assessed were met Staffing is provided according to the needs of the service users. Staff roles and responsibilities are clearly defined within the home. The home has a comprehensive Recruitment and Selection policy that is provided by the health authority. The Manager/staff confirmed that supervision sessions have re-commenced and are carried out every two months. Records showed that new staff have a comprehensive Induction at the home, and all staff have regular training to up date their current skills/knowledge or learn new skills to meet the changing needs of the service users. Conduct and Management of the Home (Standards 37 ­ 43) 6 of the 7 standards assessed were met The manager has now been in post for a number of months and is qualified, competent and experienced to run the home and many areas have been improved greatly since the last inspection. The manager is currently in the process of completing the registered managers award. Was evident from discussion with the Manager that staff have a commitment to the rights of the service users and create an atmosphere of openness within the home. Evidence was seen that the records and finances were managed properly. The home provides a safe environment for the service users, with evidence of regular servicing of equipment and servicesOak ClosePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 1 19 YA34 The manager must ensure that newly appointed staff are subject to a three month probationary period. The manager must ensure that staff receive training on the use of physical intervention. 31.3.05312YA231.6.04Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS 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 and recommendations 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, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 19 YA34 The manager must ensure that newly appointed staff are subject to a three month probationary period. The manager must ensure that staff receive training on the use of physical intervention. The registered manager must ensure the statement of purpose and service user guide are completed and available in the home. The registered manager must ensure that the wall surface where the vanity unit has been removed is repaired and re-decorated. 31.3.05312YA231.6.044YA11.5.04519YA241.5.04RECOMMENDATIONS 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) Oak Close Page 9 No.Refer to Standard * YA32 YA37Good Practice Recommendations1 2The registered provider must ensure that 50 of care staff have NVQ level 2 by 2005. The registered manager must ensure that she completes the NVQ 5 by 2005.* 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.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: YES YES NO YES YES NO YES NO YES YES YES YES YES YES NO NO NO YES NO YESOak ClosePage 10 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)5 0 0 YES YES YES YES X X 29/3/04 11.00 5The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards 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 11 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, 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. 288 365 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are 1 Key findings/Evidence Standard met? The statement of purpose and service user guides are currently being reviewed and should be completed within three weeks.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 inspection.Oak ClosePage 12 Standard 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 inspection.Standard 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 inspection.Standard 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. 3 Key findings/Evidence Standard met? Each service user is issued with a contract and statement of terms and conditions when they move into Oak Close, then each year they are provided with information regarding any change in fees. The contacts were seen by the inspector for two service users and contained all the relevant information and it was evidenced that family, friends and advocates supported service users where appropriate when drawing up the contracts.Oak ClosePage 13 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. 3 Key findings/Evidence Standard met? Each service user has an individual plan, this is well detailed and in formats that the service user understands. They are developed with the service user and their families; they were agreed and signed by the service user. The plan describes any restrictions on choice and freedom and this is well detailed and agreed with the service users representative. The procedures detailed for service users that may be aggressive or cause self-harm are well documented. The plans are reviewed every three months and a full review with the social worker is every year. The plans are reviewed at least every six months; the new service users are initially reviewed every 4 weeks.Standard 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 inspection.Oak ClosePage 14 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. 3 Key findings/Evidence Standard met? Service users are able to participate in the day to day running of the home. Meetings are held every two months, which all service users are able to attend. The Tenant Participation officers post has now been filled and this has helped in the involvement of service users and is currently looking to provide a notice board in each house giving up to date information to the service users without them having to go to the office. The manager has completed a couple of satisfaction questionnaires that service users have completed. Standard 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 inspection.Standard 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 inspection.Oak ClosePage 15 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 inspection.Standard 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 3 Key findings/Evidence Standard met? Service users are encouraged to fulfil their potential many attend a local day centre and take part in fulfilling activities at the day centre and at Oak Close.Oak ClosePage 16 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 inspection.Standard 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 inspection.0Standard 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 inspection.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? Daily routines and house rules promote independence this was observed by the inspector on the day of the inspection. Service users that wish or are able to have a key to their rooms are offered one. Staff were observed to interact extremely well with the service users.Oak ClosePage 17 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 and these were seen by the inspector 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.Oak ClosePage 18 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 procedure 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. 3 Key findings/Evidence Standard met? Care plans are clearly written showing preferences and requirements. Service users are well presented and confirmed they have choices regarding bathing and clothing The inspector had some concerns at the last inspection regarding personal hygiene, nails and teeth were not regularly cleaned and some service users did not always have a shave, this has now been addressed and is documented in the plan of care. Standard 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 19 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. 3 Key findings/Evidence Standard met? Receipt, administration and disposal of medication is correctly documented and safe systems were being operated. Regular audits were being carried out by the contracted pharmacyStandard 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. 3 Key findings/Evidence Standard met? The ageing, illness and death of service users is dealt with sensitively and respect. The manager has recently discussed these issues with the service users and their families to ensure the home is aware of their wishes. This has been documented for each service user and kept in their personal files, one was seen by the inspector it was very good and contained all the required information it was signed either by the service user their family.Oak ClosePage 20 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 times-scales 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 NCSC Percentage of complaints responded to within 28 days 0 0 0 0 0 0 100 3 Key findings/Evidence Standard met? There is a complaints procedure, however this is only displayed in the office it is not available in the houses, it has been suggested that notice boards are provided in each house to display such information and the manager is trying to implement this. Information seen by the inspector confirmed that complaints were dealt with promptly and appropriately with outcomes discussed.Oak ClosePage 21 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 YES02 Key findings/Evidence Standard met? The manager had available the Rotherham Council adult protection policy. There was also a whistle blowing policy. Training on the use of physical intervention is required, as this has not been addressed.Oak ClosePage 22 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. 2 Key findings/Evidence Standard met? The home was well maintained, clean and homely. A large amount of decoration has been carried out since the last inspection. The patio area has been greatly improved and is safe and accessible to all service users. The vanity unit in the bathroom in house that was causing problems has now been removed however the wall surface needs making good this is to be carried out in the next four weeks.Oak ClosePage 23 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 The rooms meet the requirements of the standards. YES NO NO 17 5 0 0 Standard met? 3 17 00 0 0 0Oak ClosePage 24 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. 3 Key findings/Evidence Standard met? All the service users bedrooms are provided with furniture and fittings suitable and sufficient to meet their individual needs.Standard 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. 3 Key findings/Evidence Standard met? The toilet and bathroom facilities provided meet the needs of the current service users.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. 3 Key findings/Evidence Standard met? The shared space in each house was safe, accessible and well maintained with separate areas provide for private use if required.Oak ClosePage 25 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 inspection.Standard 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 inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? Not assessed at this inspection.Oak ClosePage 26 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 inspection.Oak ClosePage 27 Standard 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. 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 5 11 0 713 5 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 752 Nursing X X X07.462 Key findings/Evidence Standard met? Five care staff have NVQ level 3 and a further nine are in the process of completing level 3. There are plans by the Trust to meet the target of at least 50 to level 2 or equivalent by 2005.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. 3 Key findings/Evidence Standard met? Staffing is arranged flexibly to cover the needs of the service users, with more staff around during early mornings and evenings, when day service attendees are at home. There is always a registered Nurse (Learning Disabilities) on duty least 24 hours a day. Qualified staff meeting are held monthly, and meeting for nursing assistant have also now commenced.Oak ClosePage 28 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? A thorough recruitment process is followed. Two references are obtained and a CRB check prior to employment. Service users have been involved in the selection process in the past and would be in future. Staff have all received copies of the GSCC codes of conduct. Staff appointments are not subject to a minimum three probationary period. The manager has raised this with her trust manager and has still to be resolved. 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? There is a training and development programme and each member of staff has a training and development file. All mandatory training was up to date and specific training is devised around service users needs.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? All staff receive supervision every two months records were seen by the inspector and they were all up to date. Staff also receive annual appraisals.Oak ClosePage 29 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 or equivalent. NO2 Key findings/Evidence Standard met? The manager has now been in post for a number of months and is qualified, competent and experienced to run the home and many areas have been improved greatly since the last inspection, which confirms this. The manager is currently in the process of completing the registered managers award. The manager commenced NVQ level 5 in management and care in September and is due to complete the course in JulyStandard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The management approach to the home definitely creates an open, positive and inclusive atmosphere this was evident during the tour of the premises by the inspector. There is now a tenant participation co-ordinator who has produced an action plan for the year around activities and day to day running of the home. They will visit regularly to determine if the action plan is being adhered to.Oak ClosePage 30 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 and relatives meeting. The registered provider carries out regulation 26 visits monthly. The manager carries out regular audits. There are regular resident satisfaction questionnaires carried out.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 Younger Adults. 3 Key findings/Evidence Standard met? The home has good policies and procedures, issued by both South Yorkshire Housing Association and the Rotherham NHS Trust these are continuously monitored and reviewed when required. The polices and procedures cover all the topics required by the standards. Policies and procedures are kept secure in the office all staff have access to the office and service users and relatives are also able to see the policies and procedures on request.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 ? All records are maintained and up to date. Personal files are kept securely in the office. Service users have access to these if they so wish.Oak ClosePage 31 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. 3 Key findings/Evidence Standard met? All mandatory training is carried out. First aid is being addressed with all registered nurses to attend thereby become registered first aiders. Then there will always be a member of staff on duty with the certificate. All maintenance is carried out records seen by the inspector were up to date. There were no window restrictors upstairs in houses 3 and 4, risk assessments have now been carried out for these windows. Risk assessments are carried out on all safe working practices. All staff receive a thorough induction and the package is currently being developed to meet TOPSS specification. Standard 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. 3 Key findings/Evidence Standard met ? The manager has two budgets these are from South Yorkshire Housing Association and Rotherham NHS Trust. These were seen by the inspector there was enough allowances for each individual item and the manager was maintaining the budgets within the limits still providing what was needed by the service users. There are regular visits by SYHA and NHS Trust to monitor the budgets. The home had a business and development plan.Oak ClosePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Compliance Named service users over the age of 65 are allowed to remain at Oak Close. Comments If they should leave this condition would be removed.YESCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateSarah Powell Ann MicklethwaiteSignature Signature SignatureOak ClosePage 33 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Oak ClosePage 34 PART EE.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 29th March 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the NCSC in response to provider comments: Oak Close Page 35 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual 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 accurateNONONONote: 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 planYESOther: enter details here Oak ClosePage 36 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I 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 above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I 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 above date(s) 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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