Inspection on 10/03/06 for Oak House

This inspection was carried out on 10th March 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oak House 12/12/06

Oak House 23/11/05

Oak House 16/02/05

Oak House 12/10/04

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

CARE HOME ADULTS 18-65 Oak House 46-50 Lysways Street Chuckery Walsall West Midlands WS1 3AQ Lead Inspector Maggie Bennett Unannounced Inspection 10th March 2006 10:45 Oak House DS0000020831.V286024.R01.S.doc Version 5.1 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 House DS0000020831.V286024.R01.S.doc Version 5.1 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 House DS0000020831.V286024.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Oak House Address 46-50 Lysways Street Chuckery Walsall West Midlands WS1 3AQ 01922 720118 01922 722789 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) Caldmore Area Housing Association Limited Ms Julie Wakefield Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2005 Brief Description of the Service: Oak House provides residential accommodation for 12 adults who have a mental disorder. The home aims to assist its service users to live independently in the community. Service users and staff at the home have close links with the mental health multi disciplinary team. The accommodation at Oak house is over three floors and there is no lift. All bedrooms are single and three have an en suite facility. There is one bedsit, with a kitchen area. There are ample communal areas, including a conservatory. To the rear there is a large, well-tended garden. Service users have the use of a training kitchen in which they can prepare and cook their own meals and do their laundry. Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday between 10.45 a.m. and 4.35 p.m. On this occasion, key standards not inspected or not met at the last inspection were assessed. It was found that 3 of the statutory requirements made at the last inspection had been met and 2 were in the process of being met. No further statutory requirements were made following this visit. During the course of the visit six service users were spoken to and discussion also took place with 2 members of staff and the manager of the home. The Support Plan of one service user was seen and the medication and accompanying records were inspected. What the service does well: What has improved since the last inspection? The assessment process has been tightened up and the home now ensure that no new service user is admitted until a copy of the Care Management Assessment has been received. The medication audit system, introduced in late 2005, is proving to be a valuable tool in ensuring that there are no mistakes in medication administration. Improvements to the physical environment are ongoing. Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 There are comprehensive assessment procedures in place to ensure that the home is aware of service users’ needs and aspirations prior to their moving to Oak House. EVIDENCE: This standard was not met at the last inspection, as the home had admitted 3 service users without obtaining a Care Management Assessment. On this occasion the standard was fully met. The Support Plan of the most recently arrived service user was seen and it was found that all the required assessment information had been obtained prior to the person moving to the home. This information included reports from the Community Psychiatric Nurse and the Occupational Therapist. The Plan also included a risk assessment. A comprehensive Support Plan had been developed in conjunction with the service user, based on the Care Management Assessment and the home’s own assessment. Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 The home is currently working with the Primary Care Trust to ensure an appropriate policy with regard to Confidentiality. EVIDENCE: Standards 6 and 7 were exceeded at the last inspection and Standard 9 was met. As stated following the last inspection, the home has a Confidentiality Policy, details of which are published in the Statement of Purpose. A Statement of Confidentiality to partner agencies is being developed and discussions are taking place with the Primary Care Trust. It is hoped that this will be completed in the near future. Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15, 16 and 17. Service users are assisted to take part in various educational and work-related opportunities. The service users’ rights to have appropriate personal, family and intimate relationships are upheld. During the inspection service users confirmed that their privacy was respected at Oak House. Service users also confirmed that the food provided by the home was of good quality and that they were assisted in their cooking skills. EVIDENCE: Standard 13 was met at the last inspection. Service users are assisted by staff to join various appropriate activities in the local area. One person is attending “Learn Direct”, one is going to College and several people are attending courses at Broadway North. Service users are also able to access assistance from an Employment Advisor, who is part of the multi disciplinary team. At present there are no service users who have paid or voluntary work. Service users spoken to during the inspection confirmed that they were assisted with budgeting skills. Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 11 Visits to and from family and friends are encouraged. Some of the service users spoken to confirmed that they frequently visited their families, sometimes staying over, and their friends. They also confirmed that visitors were welcome at Oak House. Families are also invited to celebrations at the home and some attended a Christmas meal. All service users have their own single rooms, with locks to their rooms and a lock to the front door. Service users spoken to confirmed that their privacy is respected at the home. It was observed during the inspection that staff talk with service users and not exclusively with each other. One service user, however, said that he wished staff would sit down and talk with the service users more often. All service users have unrestricted access to the communal areas of the home. Service users are responsible for cleaning their own rooms and there is a rota in place for keeping communal areas clean after tea-time. Cleaners are employed during the day-time. The home’s rules on smoking, alcohol and drugs are clearly stated in the contract. Three meals are provided at Oak House on a daily basis: breakfast, lunch and evening meal. The lunchtime meal is usually a snack, the main meal being taken in the evening. Service users are also able to cook their own meals in the “training” kitchen and assistance is provided from staff, both in terms of budgeting for food, menu planning and appropriate diet. A weekly menu is prepared, with assistance from the service users, but there is always a choice if the service user does not like what is on the menu. Service users are able to eat in the dining room, or in their rooms if they wish. Nutritional needs are discussed with service users and these needs are noted on service user plans. The kitchen was seen at the inspection and was in good order. Fridge and freezer temperatures are taken on a daily basis. During the inspection service users described how they are assisted to take more responsibility for shopping for and preparing their own meals. They also said that the food provided by the home is of good quality and that there is always a choice. Several service users attend a Men’s Group, where they receive advice with regard to healthy eating. Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The are robust policies and procedures in place with regard to medication, which protect the service users. EVIDENCE: Standards 18 and 19 were met at the last inspection. Although Standard 19 (Healthcare) was not inspected on this occasion, it was pleasing to note that an Advisor was to visit the home and to speak with those service users who wished to with regard to a “Stop Smoking” course. All service users have a lockable facility in their rooms in which to keep medication if they self-administer. Service users who do take charge of their medicines do so on a gradual basis, within a risk management framework. A random sample of the medication and administration sheets was seen at the inspection and there were no discrepancies. It was noted that the home provide handwritten administration sheets for clozaril, as this medication comes direct from the Hospital and is not supplied by the home’s Pharmacist. The home carry out a daily audit of the medication. Records are kept of all medicines received, administered and leaving the home. All staff who administer medication have received accredited training. The home regularly seek advice from their Pharmacist and have also consulted the Pharmacist Inspector from the Commission. Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 There are robust procedures in place to protect service users from abuse. EVIDENCE: Standard 22 was met at the last inspection. The home has a robust Adult Protection Procedure in place, which is in line with the local Social Services Procedures and the Department of Health document, “No Secrets”. The majority of staff have taken part in Adult Protection training. There are policies and procedures in place with regard to any physical and verbal aggression by a service user. This is particularly important at Oak House, where care staff often work alone. Several service users request that the home keep monies in safe keeping on their behalf. These monies are safely stored and accessible to service users at all times. Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None. Although it is an older property, Oak House is generally well-maintained and provides warm and comfortable accommodation. EVIDENCE: Standards 24, 25, 27, 28 and 30 were met at the last inspection. Service users have recently been involved in choosing wallpaper, paints and a new suite for the lounge, which is shortly to be re-decorated. Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 Staff are competent and given good opportunities for training. Service users spoken to are very satisfied with the care they receive. EVIDENCE: Standards 34 and 35 were met at the last inspection. Service users spoke very positively about the staff and the assistance they received from them. One person said that they were “very helpful” and were “nice people”. Another person, although very happy with the staff, said that he would like staff to be able to spend more time chatting with the service users. Staff take part in a number of relevant training courses and the majority have completed the NVQ and accredited medication training. In addition to the training provided by the Company, staff meet regularly with the Community Psychiatric Nurse and Consultant Psychiatrists from the multi disciplinary team. Some members of staff would like the home to re-instate the weekly in-house training sessions on mental health issues, which had lapsed of late because of the need to complete NVQ training. Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 39. The manager is well supported by her staff in providing clear leadership throughout the home, with staff demonstrating an awareness of their roles and responsibilities. There are good systems in place for seeking the views of service users, their representatives and visiting social and healthcare professionals. EVIDENCE: Standard 42 was met at the last inspection. The Registered Manager is experienced and well qualified, having achieved the Registered Managers’ Award and the NVQ 4 qualification in care. She is respected by the service users and staff. The manager has a clear job description to ensure that the Standards listed in 37.3 are met. The manager updates her skills by periodically taking part in relevant training. As noted at the last inspection, there are good systems in place for seeking the views of service users, their representatives and visiting social and healthcare Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 17 professionals. Service users have been involved in choosing wallpaper, colours, floor covering and furniture for the re-decoration of the lounge. As at the last inspection, service users were given the opportunity to speak with the Inspector and discuss their views of the home. Although there is evidence that a representative of the Registered Person visits the home on a monthly basis and provides a written report, this report is not being forwarded to the Commission. The Registered Manager undertook to ensure that these reports were forwarded to the Commission from now on. Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 N/A 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X 2 LIFESTYLES Standard No Score 11 X 12 4 13 X 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 3 X 2 X X X X Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? N/A 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 YA10 Regulation 12(4)(a) Requirement The home must provide a statement on confidentiality to its partner agencies, setting out the principles governing the sharing of information. (It is understood that such a statement is currently being developed with the Primary Care Trust). (Previous requirements of 30/06/05 and 28/02/06 not met). A representative of the Registered Persons must visit the home each month and prepare a report on the conduct of the home. A copy of this report must be forwarded to the Commission. (Previous timescale of 30/11/05 not met). (Although these visits have been taking place, reports have not been forwarded to the Commission). Timescale for action 30/04/06 5. YA39 26 10/03/06 Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 20 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 2 Refer to Standard YA32 YA35 Good Practice Recommendations It is recommended that staff spend more time sitting and talking with service users. It is recommended that staff are consulted about the reinstatement of weekly in-house training on mental health issues. Oak House DS0000020831.V286024.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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