Inspection on 30/11/07 for Oak Cottage

This inspection was carried out on 30th November 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oak Cottage 30/04/09

Oak Cottage 26/11/08

Similar services:

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

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

CARE HOME ADULTS 18-65 Oak Cottage Oak Street Merridale Wolverhampton West Midlands WV3 0AD Lead Inspector Deborah Sharman Key Announced Inspection 30th November 2007 09:30 Oak Cottage DS0000070082.V350962.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 Cottage DS0000070082.V350962.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 Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oak Cottage Address Oak Street Merridale Wolverhampton West Midlands WV3 0AD 01902 861 235 01902 655 793 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) Osei Minkah Care Limited Mrs Karimah Francis Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care (excluding nursing) and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following category: - Learning disability (LD 3) The maximum number of service users to be accommodated is 3. 2. Date of last inspection This is the first inspection for Oak Cottage Brief Description of the Service: Oak Cottage is a detached house in a residential area of Wolverhampton within a ten minute drive of the City Centre. The service is currently registered to accept 3 service users whose primary needs are learning disability. However this is under review as the Provider has applied to the Commission for Social Care Inspection to vary this. The property is domestic in style and is comfortably furnished in a light and modern style. There is a lounge and a conservatory that offers alternative seating. There is a small patio to the rear of the property and plenty of parking spaces for cars at the front. All 3 bedrooms, which are on the first floor, are single occupancy and have a washbasin and lockable facilities. There are two bathrooms for shared use and a separate laundry. The aim of the service is to provide person centred care in a warm, safe and enabling environment ensuring that service users have optimum control over their lives. Information relating to fees is not currently contained within information about the service Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this unannounced key inspection between 9.30 am and 5.30pm. A CSCI Senior Manager shadowed the Inspector throughout the inspection day. It is usual to carry out unannounced inspections so that no one associated with the home receives prior notification and are therefore unable to prepare. However, for a variety of reasons but primarily to ensure that there was somebody in, we gave the home 48 hours prior notification. As it was a key inspection the plan was to assess all National Minimum Standards defined by the Commission for Social Care Inspection (CSCI) as ‘key’. These are the National Standards which significantly affect the experiences of care for people living at the home. As this was the home’s first inspection they were not required to provide written information about the home in an annual return so this information was not available to us in advance of the inspection. However prior to inspection, the Commission for Social Care Inspection sought the views of the service user currently staying at Oak Cottage and other third parties associated with the home by sending out surveys. No written responses were received. However prior to inspection we did have the opportunity to speak by telephone to the Registered Manager, a Social Services Team Manager, the Placing social worker and a relative of the person presently living at Oak Cottage. We were also able prior to undertaking the inspection, to clarify registration matters with the Inspector from CSCI who recently registered the service. All this information was analysed prior to inspection and helped to formulate a plan for the inspection and has helped in determining a judgement about the quality of care the home provides. During the course of the inspection the Inspector used a variety of methods to make a judgement about how service users are cared for. The Registered Manager was available throughout the inspection day to answer questions and generally support the process. On arrival we spoke privately with the person living there for well over an hour. She was able to tell us about her experience of the care she is receiving. We then assessed in detail the care provided to her using care documentation and by discussing her needs and care with the manager. We toured the premises, observed interaction between the Manager and the service user and sampled a variety of other documentation related to the management of the care home such as maintenance of the premises, complaints and the recruitment of staff. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Manager must now concentrate on developing systems that comply with Care Standards regulations. The admission of the current service user was unusual in that it was an emergency admission with very little time to prepare. However, the national minimum standards outline what should happen in these circumstances and practice has fallen short of this. The Manager did not obtain written information from the placing agencies and did not undertake her own assessment. Also the written information she has provided to agencies about her service does not clearly outline the needs of people that she is registered to accommodate. The information provided is ambiguous and as a result, the current service user based on information available at the time was admitted contrary to the homes registration. This does not assure service users and their relatives that their needs will be known and that they will be appropriately admitted to the home. The Manager described how early in the placement she had unknowingly provided food that contravened the service users cultural requirements which angered a relative. This could have been prevented by an earlier assessment. The Manager has since applied to us to vary her registration and this is being processed. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 7 The Manager has got to know the service user well and three months after admission has carried out a detailed assessment of need. Brief care plans are in place but she now needs to use this assessment information to develop robust care plans. This will be particularly important as the service develops and more staff are employed to ensure that staff know how to provide the care in an acceptable and consistent way. The Manager was able to describe some risks she is aware of that are pertinent to the service user and in practice there are measures to control risks. For example the service user is supervised using the kettle and when out in the community. The Manager must however formally consider the risks and carry out individualised written risk assessments. She was advised to ensure that in future these are carried out prior to admission, or in the event of an emergency placement, without delay thereafter. The most significant areas of concern arising from this inspection were in relation to medication management and recruitment practice: Medication systems are poor, falling well below the expected national minimum standard. Systems are not accountable. For example, there is not a record of medications received into the premises, no record of medications administered, an indication that medication administered at the weekend is signed for days after being administered (although records to confirm the managers account were not available) and no evidence that very significant changes to prescribing direction had been medically authorised. The service user told us that she would like to be responsible for managing her own medication. The Manager felt that this would be too much of a risk. The risk however has not been considered in a risk assessment or care plan to account for the limitations imposed or to consider how the service user could be involved to maintain and promote skills, independence and dignity. Similarly recruitment practice is poor. Only one person is currently employed other than the Manager. Neither a Criminal Record Bureau check nor a POVA first check (a check against a national list of people unsuitable to work in care) had been obtained prior to employment and to date no references have been obtained. This is in conjunction with no self-declaration of any prior criminal offences, work or education history. The Manager described the circumstances of the appointment to us. She explained how she had informally assessed the risk to be low and is aware that the responsibility lies with her. A number of other people have been provisionally appointed and are waiting a start date. These people have been appointed using Criminal Record Bureau checks from other employers, which the Manager thought was acceptable. This would not give the Manager an up to date check against the POVA list and is unacceptable practice. It was agreed with the Manager that these staff would not work until full and up to date disclosures had been obtained and in the event of the need for further staff cover, that she would employ agency staff in the meantime to better assure service user protection. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 9 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 Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is poor. The Manager has not taken sufficient steps to assess the needs of a service user placed with her in an emergency. Written documentation about the service available to third parties is ambiguous and misleading. Consequently a service user has been admitted contrary to the homes registration. However, there are no concerns about how the service users needs in practice are being met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager has admitted her first service user contrary to her legal registration. Although the service user was placed at Oak Cottage as an emergency on the day of referral, sufficient steps were not taken to ensure that her admission complied with the homes registration. The Manager met with social workers to obtain a verbal account of her needs immediately prior to admission but did not obtain written information from the placing authorities and did not undertake her own assessment until some three months later. In an emergency situation assessments should be carried out within 5 days. The Manager is aware of what risks there are for the service user and is taking measures to limit those she knows of but has not carried out any formal risk assessments. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 11 Written documentation about the homes intentions and purpose is available but is not sufficiently clear about who the home can admit and would mislead placing authorities and other enquirers. The documentation also refers to the sizes of 5 bedrooms which again gives the impression that 5 people can be accommodated, when the home is registered for 3. This was amended at the time of inspection. A contract is available for service users but one has not been issued to the service user living at the home. The Manager said there was no reason for this other than she had expected the placement to be very short term. All service users must be issued with a contract so they are fully aware of the terms and conditions of their stay. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is adequate. The Manager is aware of the service users needs and how to minimise any risks but must develop systems to support this so sufficient guidance is available to staff. The service user is satisfied that her choices and decisions are respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager has got to know the service user well and understands her nonverbal cues when she doesn’t verbally express what she needs. The manager was able to evidence how small but significant steps have been taken to meet these needs. For example bathroom doors are left open, protection provided on the bed, favourite culturally appropriate foods are provided at appropriate times of the week and personal shopping has been supported at the providers expense. The knowledge that the Manager has about how to meet these and other assessed needs must now be outlined in a plan of care. The current care plan is very brief and required intervention is not described and all known Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 13 needs are not included. The Manager said the current brief ‘care plan’ was a multidisciplinary effort that included the service user although this could not be evidenced. It was positive to see that a well-recorded review meeting had taken place with the social worker a month following admission and it was clear from this that the placement was positive for the service user. Following a difficult start the Manager is now aware of the service user’s cultural routines and rituals and these should also be described in the care plan for access by current and future staff. The Manager was aware of some risks which are pertinent to the service user. We observed the Manager take action to minimise risk in the kitchen for example when supporting the service user to make a cup of tea. Four months after admission, risks and ways to control them have not been formalised. The Manager has formats available for this and must now prioritise it. We suggested that staff read and sign all risk assessments to acknowledge that they have read them and are familiar with what is expected of them. Discussion with the service user in conjunction with some evidence in records evidences how the service user is supported to make choices and decisions. She said that she can go to bed when she wants to, can get up when she wants to, go out as much as she wants to and chooses what she has to eat. She explained to us that there aren’t really any rules or restrictions placed upon her. The service user said that she likes it at Oak Cottage because there isn’t any one ‘bothering her’. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. Family contact is supported and encouraged and routines are service user lead. Activities are limited by lack of income but the current service user appears content. The service user enjoys her meals and those provided meet cultural needs, expectations and preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service user attends a day centre five days a week and said that she enjoys this. Now that her religion has been identified she is also supported to attend church and the Manager said that the service user has been befriended there. This is giving her the opportunity to make friends within the local community with people who do not share her illness, away from the care home. Although the service user said she can go out whenever she wants, it was difficult to evidence how her leisure time (e.g. evenings and weekends) is Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 15 spent. There was little reference to this within daily records, it is absent from care planning and the service user said that she is not aware of local facilities but would like to start jogging. The Manager said that she goes for walks with staff and occasionally goes shopping but acknowledged that it has been difficult to arrange activities without a source of funding. However in light of this the Manager is to be commended for taking the service user to Butlins for three weeks in September at her own expense. The service user has contact with her family through visits and telephone calls and they support some leisure activity by bringing videos that she enjoys and taking her out from time to time. The service user told us that she does not have a key to her bedroom and would like one. Upon checking this with the Manager we learned that one had been provided but had been lost. The Manager said that she gave a replacement key to the service user following feedback about this and during a later tour of the premises, in the absence of the service user her room was locked. The service user is satisfied with how her mail is managed. She said that it is given to her unopened but that staff help her with the contents if she needs them to. Food stocks were low but the Manager explained that Friday, the day of the inspection is usually shopping day. The service user said she has plenty to eat, enjoyed the meals that meet her preferences and can have drinks and snacks whenever she wants to. The Manager confirmed that the service user eats well and has put on weight since admission. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is adequate. Service users can be assured that their personal care and health screening needs will be met with privacy and dignity assured throughout. Systems to support this however e.g. care planning and record keeping could improve to better describe and evidence care needed and provided. This will better assure continuity of care especially as the home develops and grows. Medication systems are unaccountable and poor. The Provider / Manager could not evidence that medication is being administered as prescribed. This must be prioritised for improvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspector has queried how continence needs are met for a female service user when a male staff member, new to care work is on duty alone. The manager said that this has not presented as a concern and that she is contactable in the event of him needing support. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 17 The service user is satisfied with the arrangements for personal care. She said that there is always enough hot water and a choice of bath or shower. She can lock the door for privacy but staff are available to help when she needs them to and she is happy with how help is provided. Health appointments have been kept and are recorded in daily records. Chiropody treatment provided at the homes expense has positively affected outcomes for the service user as a source of discomfort has been treated. The Manager intends to record health appointments separately from daily care records, which will help her to monitor them more easily. The service user said she is confident that staff would help her if she were feeling poorly. Medication systems are poor, falling well below the expected national minimum standard. Systems are not accountable. For example, there is not a record of medications received into the premises, no record of medications administered, an indication that medication administered at the weekend is signed for days after being administered (although records to confirm the managers account of this were not available) and no evidence that very significant changes to prescribing direction had been medically authorised. The changes in prescribing direction meant that the home did not administer medication as morning and lunchtime doses were sent to the day centre to administer Monday to Friday. The Medication Administration Records were also sent to the centre. This means that the first dose of the day will have been administered sometime after mid morning. The optimum administration times are not known (but have since been confirmed as between 8am and 10am). Medication Administration Records were not available to evidence administration at the home prior to this change in direction or to evidence administration by the home at weekends. The Manager said that she drives to the day centre on a Monday to sign for medication administered at the weekend. There was no documentary evidence of this but it remains unsafe and unsatisfactory practice. The Manager said she has recently completed training in the safe administration of medication and is the only person to have done this to date. She said therefore that only she has administered medications and prior to the reported change in prescribing direction she solely was administering medication morning, noon and night. This could not be verified due to the total absence of records. The service user told us that she would like to be responsible for managing her own medication. The Manager felt that this would be too much of a risk. The risk however has not been considered in a risk assessment or care plan to account for the limitations imposed or to consider how the service user could be involved to maintain and promote skills, independence and dignity. The service users written consent to the administration of medication has not been Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 18 obtained in line with the homes own policy and the national minimum standard. Controlled drugs are not being held on the premises. Medication is stored in a lockable cupboard within the laundry. The Manager needs to monitor the temperature of this room daily as the stability of medications stored in temperatures over 25 degrees can be affected. The Manager agreed to urgently review medication practice with the GP and a Community Psychiatric Nurse immediately following the weekend and without delay to confirm in writing to CSCI remedial action taken to improve practice. The Manager feels that at no time was the service users health, safety or welfare compromised. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is adequate. There have not been any incidents that have compromised the protection of the service user and policies and procedures are in place to promote their protection and well-being. The Manager would benefit from undertaking refresher training in adult protection to clarify her responsibilities in her new role. The service user feels safe at Oak Cottage. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In the short time that it has been open the home has not received any complaints. All parties appear to be satisfied with the care provided. The service user said she would feel able to tell the manager if there was something she wasn’t happy with, as she is approachable. Policies and procedures are available to guide staff and the manager in the event of receiving a complaint. We advised the manager to ensure that information about how to make a complaint should be readily accessible at all times to people living at and visiting the home. All policies relating to service user protection with the exception of Wolverhampton’s multi agency safeguarding procedures were available. The Manager undertook to obtain a copy to ensure that full information is available on site to guide action should it be necessary. There have been no accidents, incidents, restraints or staff performance issues that have compromised the service users safety or protection and she reported feeling safe. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 20 The Registered Care Manager is a qualified Social Worker and has worked as a social worker until recently. Discussion shows that she needs to be clear about the difference in these roles in the event of their being an adult protection allegation or concern. The Manager said that she undertook adult protection training as a social worker about 4 years ago and agreed that she should undertake refresher training related to her new role. The homes policy is not to physically intervene in situations which may have escalated, but to work towards avoiding situations escalating in the first place. There is a note on the care plan who to contact in the event of a deterioration in mental health and triggers to identify this are described. The care plan however does not provide sufficient guidance as to how to actively support continued good mental health or how staff should respond to ways in which mental ill health may manifest itself. The management of service users monies could not be assessed at this inspection. However discussion showed that the manager is aware of her obligation to keep full records and account for all expenditure. Systems are in place to help her to do this when circumstances permit. Recruitment practices are not fully protecting service users. A new and inexperienced staff member is working alone without the assurance of full and satisfactory checks, references and associated documentation. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome area is good. Oak Cottage provides service users with a clean, homely and safe living environment that is domestic in style and meets current needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home showed it to be warm, comfortably furnished, clean and safe with no obvious dangers. Hazardous chemicals are locked away, fire doors that are left open are fitted with an appropriate device to close them in the event of a fire and there are no obstructions or trip hazards. The service user is pleased with her bedroom and said she has everything that she needs. We did not inspect the service users bedroom as the manager explained she had locked it before going out to day centre. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 22 Risk assessments have been carried out for each room and we advised that windows are included in this as they are currently not restricted. Communal areas are modern, light and comfortable and the environment meets the needs of the service user currently living there. This service user’s bedroom is the only one fitted with carpet. All other rooms have laminate flooring, which is more readily cleanable than carpet. The suitability of carpet in this service users room should be kept under review. The kitchen and laundry and facilities within them are clean and cleanable. It was noted that the laundry must be furnished with paper towels, disposable gloves, aprons and liquid soap. Environmental Health carried out a Food Safety inspection with no concerns identified. This limits the risk of service users acquiring a food borne illness. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is adequate. Lack of evidence made it difficult to fully judge staffing but the service user described staff as kind and always available. Recruitment practice is poor, but in the particular circumstances the Manager believes any risk to be minimal. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is one service user currently placed supported by a staffing complement of two staff members including the Manager. It was not possible to assess how staffing had been provided as rotas have not been maintained. It was reported to us that shifts have been agreed between the manager and the staff member with both recording their shifts in personal diaries. This is not acceptable, does not comply with regulation and hampered the inspection of staffing levels, shift patterns, staff sufficiency and safe recruitment. The Manager agreed to develop a rota for the following two weeks and to submit copies to us. Staff availability was discussed with the service user who said staff are always available. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 24 Recruitment practice is poor. Only one person is currently employed other than the Manager. This person has been employed for nearly 3 months. Neither a Criminal Record Bureau check nor a POVA first check (a check against a national list of people unsuitable to work in care) had been obtained prior to employment and to date references still have not been obtained. This is in conjunction with no self-declaration of any prior criminal offences, and no work or education history. The Manager described the circumstances of the appointment to us. She has informally assessed the risk to be low upon receipt of the information available to her although the staff member is inexperienced and is lone working at times. She is fully aware that the responsibility for this appointment lies with her. Additional staff have been recruited ready to call upon as service user numbers increase. As we were told that these staff have not started work, their recruitment was not assessed. Discussion with the manager indicated that new Criminal Record Bureau (CRB) checks have not been sent for, and “portable” ones less than 12 months old have been relied on. This is no longer acceptable as this does not give an accurate up to date picture of any offending history and does not provide an up to date check against the POVA list (national list of people unsuitable to work with vulnerable adults). The Manager had intended to call upon these staff in the event of needing emergency staff cover but agreed not to until full and satisfactory up to date checks have been obtained. The Manager said she would use agency staff instead should the need arise. Discussion with the Manager immediately following inspection indicated that she was also considering using these staff as volunteers. However, volunteers should be subject to the same checks as paid staff. The staff member employed has not worked in the care profession before and therefore has no relevant qualifications. However, the Manager described an intensive induction and NVQ training programme that this first staff member is undertaking with Wolverhampton Social Services training section and that she had made this a condition of his employment. The Manager is aware of the need to develop team and individual training profiles as the service develops to help her to manage the staff training programme. The service user described staff as kind but explained that staff don’t always understand her as they talk differently to her and that she finds this frustrating at times. The Manager disputed this but said that she would review the feedback with the service user. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is adequate. The Manager is managing a service that respects the service user and is generally run in the interests of the service user. There are many positive outcomes for the service user who has settled well. The Manager must now apply herself to ensuring that she develops systems that fully comply with the care standards regulations and national minimum standards to reduce risk in some areas and to evidence the management of the service in a more accountable and transparent manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager has been recently registered with the Commission for Social Care Inspection. This is a rigorous assessment process that has confirmed her to be fit to manage a care home and as such to be appropriately qualified and Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 26 experienced. The service user feels that the home is managed well and described the Manager as a ‘good manager because she is always there for us’. The Provider / Manager is not receiving formal supervision and as a small provider she will need to keep this under review. She is currently obtaining support from informal monthly meetings with other small businesses. It is positive that she has made arrangements for an independent person to carry out regulation 26 visits to the home, which are planned to begin in January 2008. She has also designed quality assurance surveys for service users that she intends to distribute annually to receive their feedback about the service. This is a good start but additional consideration needs to be given to how it is intended to assess and respond to all aspects of the homes performance on an ongoing basis. Hazardous chemicals are stored safely. Inspection has shown the need for the Manager to carry out risk assessments in respect of hazardous chemicals and unrestricted windows but it was pleasing to see that environmental risks have been formally considered in a structured way on a room-by-room basis. The need to ensure the security of service users based upon individualised assessments of vulnerability have been referred to earlier under Standard 9. All service and maintenance certificates requested by us were available and were up to date. Recent visits by an Environmental Health Officer and Fire Service Officer have shown no concerns and there have not been any accidents. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 27 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 1 2 1 3 3 4 1 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 X 2 X X 3 X Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No. This is the homes first inspection. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 6 Requirement The Statement of Purpose and Service User Guide must be fully reviewed to ensure that they represent the service user categories that the home is registered to provide care and accommodation for. This will inform potential service users and placing officers whether the home is appropriately registered and experienced to meet their needs and will avoid service users being inappropriately placed in future. New requirement arising from this first inspection November 2007. Timescale for action 14/12/07 2 YA2 14 Accommodation must not be provided to a service user at the care home unless, so far as it shall have been practicable to do so: The needs of the service user have been assessed by a suitably qualified or trained person And 01/12/07 Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 29 The registered person has obtained a copy of the assessment. This will assure service users that their needs are known prior to admission and that the care home is an appropriate place to meet their needs. New requirement arising from this first inspection November 2007. 3 YA6 15 Care plans must describe how all the service user’s agreed assessed needs in respect of his health and welfare are to be met and must be kept under review. This will ensure that sufficient guidance is available to staff to ensure that they provide continuity of care in a way that meets all the needs and expectations of service users. New requirement arising from this first inspection November 2007. 31/12/07 4 YA9 13 Steps must be taken to ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. This will protect the service user from unnecessary risk and possible injury. New requirement arising from this first inspection November 2007. 31/12/07 5 YA20 13(2) Steps must be taken to review 07/12/07 medication practice making sufficient arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This will ensure that medication Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 30 management is accountable, will minimise the risk of mishandling and will enable the home to demonstrate that the service user is administered medication in accordance with medical direction to promote good health. New requirement arising from this first inspection November 2007. 6 YA34 19 A person must not be employed to work at the care home unless it can be demonstrated that full and satisfactory information compliant with regulation 19 and Schedule 2 have been obtained in accordance with guidelines issued by the Department of Health. This will ensure that service users are protected by the homes recruitment practices. New requirement arising from this first inspection November 2007. 01/12/07 7 YA41 17(2) Sch 4(7) A duty roster of persons working at the care home must be maintained, and a record of whether the roster was actually worked. This will support the home to evidence that the home has an effective staff team who have been safely recruited that are provided in sufficient numbers to meet service users needs. New requirement arising from this first inspection November 2007. 07/12/07 Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 31 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 YA5 Good Practice Recommendations Signed contracts outlining the terms and conditions of residence should be provided to service users prior to admission or as soon as possible thereafter so they are fully aware of the rights and responsibilities of both parties. New recommendation arising from this first inspection November 2007. 2 YA9 Where practicable risks to service users and ways of controlling these risks must be assessed prior to admission to the home, or as soon as possible thereafter. New recommendation arising from this first inspection November 2007. 3 YA22 Information about how to make a complaint should be clearly visible to service users and visitors to the care home to enable them to make a complaint easily should they need to. New recommendation arising from this first inspection November 2007. 4 YA23 The Manager should attend refresher training in Adult Protection to clarify the role of a Registered Care Manager in the event of an allegation or safeguarding concern. New recommendation arising from this first inspection November 2007. 5 YA23 A copy of Wolverhampton’s Multi Agency Adult Protection Policy and Procedure should be available for reference in the care home. This will provide guidance in the event of a safeguarding concern that will enable the manager and or staff to act appropriately to protect service users in accordance with local expectations. New recommendation arising from this first inspection November 2007. 6 YA42 Risks posed by hazardous chemicals should be assessed in writing with control measures to limit risk considered and included. New recommendation arising from this first inspection November Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 32 2007. 7 YA42 Steps should be taken to assess the risk of unrestricted windows. Action should be taken (and recorded) to minimise any risks identified. New recommendation arising from this first inspection November 2007. Oak Cottage DS0000070082.V350962.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection 1st Floor Chapter House South Abbey Lawn Abbey Foregate Shrewsbury SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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