Inspection on 12/12/06 for Oak House

This inspection was carried out on 12th December 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 10/03/06

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 Key Unannounced Inspection 12th December 2006 09:30 Oak House DS0000020831.V322575.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 House DS0000020831.V322575.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 House DS0000020831.V322575.R01.S.doc Version 5.2 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.V322575.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th March 2006 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 bed-sit, 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. Fees charged at Oak House are £429.44 per week. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday between 09.30 a.m. and 6.15 p.m. All the key standards of the National Minimum Standards were inspected on this occasion. Prior to the inspection, a Pre-Inspection Questionnaire was completed by the Manager of the home. Anonymous questionnaires were sent to all the service users and 8 were returned to the Commission. During the course of the day 5 service users were spoken to. 2 members of staff were interviewed and discussion took place throughout the day with the Registered Manager of the home. The Head of Support Services for Caldmore Housing Association was also present during part of the inspection. The support plans (care plans) of 4 service users were seen in order to inspect assessment and care planning processes. The medication and administration records were seen. Staff files were inspected in order to assess recruitment processes and staff training. A tour took place of the building, during which a sample of the service users’ bedrooms were seen. Various other documents were seen in order to check health and safety procedures and policies. What the service does well: Oak House provides a very good service for people recovering from mental health problems. Service users are supported to engage in opportunities to increase and enhance their skills in order to live independently in the community. There are good assessment processes in place, which ensure that the home is aware of the service users’ needs and aspirations prior to their moving to Oak House. Care planning is of good quality. Support Plans are developed with the individual service user and follow person centred planning principles. This ensures that service users are involved in the planning of their care and are supported to take control of their own lives. There are a number of local opportunities for educational, rehabilitative and leisure-related activities. There is a good working relationship with the multi disciplinary team (Consultant Psychiatrist, Community Psychiatric Nurse and Occupational Therapist). Staff spoken to during the inspection were enthusiastic and committed and displayed a good understanding of the service users’ needs. The home provides regular and appropriate training for the staff. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 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.V322575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. There are comprehensive assessment procedures in place, which ensure that the home is aware of the service users’ needs and aspirations prior to their moving to Oak House. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files of two service users were seen in order to check the home’s assessment procedures and practice. One service user had been admitted to Oak House during the summer of 2006 and the second was commencing a trial period in order to “test out” whether the home could meet his needs. Both service users had been referred through Care Management and both files contained a full multi disciplinary Care Programme Approach assessment of their needs. An assessment had been carried out by the person’s social worker and staff from Oak House had carried out their own assessment. The assessment information covered all those details required by Standard 2.3. This information had been used to develop a Service User Plan of Care, or Support Plan, as it is known at Oak House. Each Support Plan contained a Risk Assessment. There was evidence that the Support Plan had been developed with the service user. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 9 and 10. Quality in this outcome area is good. There are comprehensive Support Plans in place, which have been developed with the individual service user and follow person centred planning principles. This ensures that service users are involved in the planning of their care and are supported to take control of their own lives. Service users confirm that they are enabled to exercise their rights and make their own decisions. All service users are subject to a risk assessment. Where risks are identified, these are discussed and decisions on how to minimise the risk are taken in consultation with the service user. The organisation has now developed a policy on confidentiality, which has been sent to partner agencies for consultation. This judgement has been made using available evidence including a visit to this service. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 10 EVIDENCE: The Support Plans of 3 service users were assessed during the inspection. These had been generated from the assessment information and set out all aspects of the individual’s personal, social and healthcare needs and how they were to be met. Some service users are subject to Section 117 of the Mental Health Act and this is clearly set out in their Support Plan. An incident of aggression by a service user, which had possibly been the result of too much alcohol, had taken place the previous evening and was to be discussed with the person’s Community Psychiatric Nurse. The Registered Manager stated that following this discussion the Support Plan may be altered and new management guidelines introduced. There is evidence that Support Plans are drawn up with the service users, but in some cases they had not signed to agree the Support Plan. All the present service users speak English, but Support Plans can be made available in different languages and formats if needed. The home operate a key-worker system. Support Plans contained notes of review meeting. Care Plans are reviewed informally with service users and key-workers on a monthly basis and at least every six months on a formal basis in a full multi disciplinary meeting. There was evidence that, following reviews, care plans are updated to reflect any changing needs. Several service users were spoken to during the course of the day and all confirmed that they were enabled to make decisions about their day to day lives. An Advocacy service is available locally and staff gave an example of one person who was using this. Decisions with regard to the choices made by the service users are recorded in their care plans. Some staff are concerned that service users are not choosing to have a healthy diet, but they recognise that the service users have the capacity to make decisions about what they eat and that it is their right to do so (see also Standard 17). Service users confirmed during the inspection that they are assisted with budgeting. All have their own accounts and are responsible for ensuring that their rent is paid. Service users work gradually towards buying their own food and cooking their own meals. Extra support is available from staff if there is a concern that a service user is not managing their budget well. Following risk assessments, individual service users receive advice if there is a fear that any of their actions may lead to harm. For example, one service user smokes in their room. The staff carry out 3 safety checks a day on the room and the furniture is fire retardant. The home do not act as appointee or agent for any of the service users. As stated above, all service users are subject to a risk assessment prior to assessment. Where risks are identified, measures are put in place to minimise them, as with the smoking risk (above). Advice is given to service users about their personal safety. There is a Missing Person Procedure in place. Currently the organisation are reviewing the needs and risk assessment process and Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 11 looking at the possibility of introducing “Advance Agreements” with service users. The organisation have recently developed a statement on confidentiality. This has been sent to partner agencies for consultation. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. Oak House has a strong commitment to enabling service users to develop their independent living skills. Service users are assisted to participate in a number of educational, rehabilitative and leisure-related activities. They are able to maintain personal and family relationships and guidance is available if needed. People are supported to make informed choices. The home encourages service users to be involved in menu planning and in budgeting and preparing their own meals. Attendance at healthy eating groups and advice from the dietician have been arranged, but this has not stopped some service users from choosing to eat unhealthily. It is considered that the home could be more flexible in terms of service users being able to make snacks at reasonable times, with service users taking responsibility for clearing up afterwards. This might result in less visits to the takeaway. This judgement has been made using available evidence including a visit to this service. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 13 EVIDENCE: Service users are assisted by staff to join various appropriate activities, both educational and leisure, in the local community. Two service users attend a group in Brownhills and travel there on the bus with their Rehabilitation Support Worker. The Rehabilitation team are in the process of setting up a new group, which will be called the “Moving On” Group. Some people attend courses at Broadway North and several go to the local Service User Enterprise Group, which is run by people with mental health problems for people with mental health problems. Support is available from a local Employment Advisor, who is part of the multi disciplinary team, although there are no service users at present who have paid or voluntary work. As stated earlier, service users confirm that they are assisted with budgeting skills. Some service users attend a healthy lifestyle group and a sports group. All service users are on the electoral register and most have decided to opt for a postal vote at election time. Any staff time with service users outside of the home is recognised as part of their duties, although on some social occasions staff may choose to attend in their own time and several do. Service users are encouraged to maintain family links and friendships. One service user stated that his mother visited each week and others said that their friends visited. One of these friends was present during the inspection. Service users are free to develop intimate personal relationships and information and guidance are given if needed. Service users confirmed during the inspection that their rights to privacy are upheld and this was observed during the inspection, with staff always knocking and seeking permission before entering rooms. All service users have their own rooms, with suitable locks and keys and a key to the front door. The Manager stated that staff would only enter rooms without permission if there were a health and safety issue and on these occasions there would be 2 staff members in attendance. All service users have unrestricted access to the communal areas of the home. Mail is given directly to the individual service users, who sign to confirm receipt. 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 a day 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 by staff, both in terms of budgeting for food, menu planning and choosing an appropriate diet. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 14 A weekly menu is prepared with the service users, but there is always an alternative if service users do not like what is on the menu. Service users can choose when and where to eat. Several staff expressed their concern during the inspection about the service users’ choice of food when they were selfcatering. These tend to be unhealthy “takeaways” and their continued use could be having a detrimental effect: one service user has recently been diagnosed with a high cholesterol level and another with borderline diabetes. Despite advice from the dietician and attendance at local Healthy Eating groups, the message does not appear to be getting across to some of the service users. This has led to the Registered Manager requesting staff to reassess all service users with regard to their nutrition. One service user said that he did not eat breakfast because he got up late and breakfast could not be taken after 10.00 a.m. He said he would like the opportunity to make a sandwich around 2.00 p.m. and would also like to be able to make toast in the evening, after 8.00 p.m. It does seem that the home could offer more flexibility with regard to the preparation and availability of snacks. It is recognised that there are health and safety issues, but if service users are being assisted towards independent living, they should have the opportunity to prepare a snack at any reasonable time, as everyone in the community does. If the decision to discontinue the use of the training kitchen in the evening is because there is a lone support worker on duty, the duty rota should be re-considered. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 15 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): Standards 18, 19 and 20. Quality in this outcome area is good. Service users receive the support they need and are consulted about their preferences. The physical and mental health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The administration and recording of medication is carried out to a good standard, with service users being protected by the home’s policies and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users are self-caring in terms of their personal support. Guidance and advice is given when needed. All service users have their own rooms. Service users spoken to during the inspection confirmed that times for getting up and going to bed are flexible. Where service users are prescribed medication, they are reminded of this if needed. It is not always possible for service users to be able to choose staff of the same gender or same ethnic, religious or cultural background to work with them. There is a designated keyworker system in place. Specialist support is provided by visiting healthcare Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 16 professionals, such as community psychiatric nurses, occupational therapists, social workers and a psychologist. Service users are able to choose their G.P. and 5 local practices are used. Specialist advice can be obtained for service users covering general health issues, such as contraception and routine screening. Service users visit local healthcare professionals, such as dentist and optician. Staff are available to go with service users on appointments should the service user need some support. Service users’ mental health is monitored and regular reviews are held with the Consultant and Community Psychiatric Nurse. Service users are assisted to attend local clinics for appointments. Service users are assisted and encouraged to gradually take charge of their own medication and all have a lockable facility in their rooms in which to keep medication. This is done within a risk management framework. An example of this was seen during the inspection, where one service user was taking charge of their medication on 2 days’ a week. A full multi disciplinary meeting to discuss this person’s progress with regard to medication had been arranged. Service users’ consent to take medication is obtained and written verification is available in their individual files. Currently the home uses a monitored dosage system for the administration of medicines. A sample of the medication and accompanying records were checked during the inspection and there were no discrepancies. There are no service users taking controlled drugs at present, but the home does have suitable storage and recording systems in place, were this to occur. All staff who administer medication have taken part in accredited training. The Manager is currently looking at the possibility of staff undertaking Advanced Medication Training. An audit of the medication and administration records is undertaken each day by the Manager, or a senior member of staff. Regular consultation takes place with the home’s Pharmacist and a further meeting is planned for mid January 2007. It was noted that the home were engaging in secondary dispensing in the case of one service user. Tablets were being cut from the card and placed into a cassette so that the service user could take them when they attended a Day Centre. It is recommended that further advice be sought on this, as it may be possible for the Pharmacist to supply the medication for these days in a separate container, thus avoiding the practice of secondary dispensing. It is also recommended that the home compile a list of specimen staff signatures. It is further recommended that when “as required” medication is not needed, this be indicated on the medication administration record sheet. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 17 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): Standards 22 and 23. Quality in this outcome area is good. There are comprehensive policies and procedures in place with regard to Complaints and how they are to be dealt with. The majority of service users feel that any complaints they have will be listened to and acted upon. There are robust policies and procedures in place for dealing with any alleged or suspected abuse and, as far as possible, service users are protected from abuse, neglect and self-harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home uses the Caldmore Housing Association Concerns and Complaints Procedure, a copy of which is given to each service user and discussed with them during their assessment period. In addition the home has a “Comments Book” to cover issues, which are not necessarily complaints, but areas of concern. The Association has a Complaints Database and monitors complaints on a monthly basis. Of the 8 returned surveys, all service users said that they would know who to speak to if they were not happy at the home. Service users spoken to during the inspection also said that they would know who to speak to if they wished to make a complaint and they felt that they would be listened to. In the returned surveys 1 person said that they would not know how to make a complaint. One complaint has been received by the Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 18 Commission since the last inspection, which is currently being investigated by a representative of Caldmore Housing Association. The Association has robust procedures in place, “Protecting Service Users”, to ensure, as far as possible, that their service users are protected from abuse, neglect and self-harm. The Registered Manager is aware of her responsibilities with regard to adult protection and since the last inspection has made an appropriate referral to the Walsall Social Services Adult Protection Team. All staff have attended Adult Protection Training and certificates were seen to verify this. It is the Association’s policy that physical restraint would not be used by staff in the event of physical and/or verbal aggression from a service user. In exceptional circumstances assistance would be sought from senior staff “on call” or the police. There are clear policies in place with regard to service users’ monies, some of who request that the home take charge of monies on their behalf. Any such monies are securely kept and accurate records maintained. A check was made of the monies and accompanying records and all were in order. An audit of the monies and records is carried out by staff on a daily basis. The Association have recently introduced a new policy with regard to Appointeeships. Where these are necessary, they will be requesting Social Services to become Appointee. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 19 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): Standards 24 and 30. Quality in this outcome area is good. Oak House is an older property, but is generally well maintained and provides comfortable and homely accommodation in a safe environment. There are good standards of hygiene in the communal areas of the home. Service users are responsible for taking care of their own rooms as part of their rehabilitative programme. This judgement has been made using available evidence including a visit to this service. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 20 EVIDENCE: Oak House is a three storey Victorian property. There are no parking facilities, but the home is within easy reach of Walsall and bus routes. The home meets the needs of its current service user group. Because of steep stairs and the absence of a lift, the home would not be suitable for any service user with a physical disability. The home has sufficient communal space. The home does not offer respite or emergency admissions. There is a separate large lounge, dining room and conservatory. A small smokers’ lounge is provided. The premises are generally in good order, with redecoration taking place on a regular basis. The Fire Officer last visited in June 2005 and made several recommendations, all of which have now been met. All service users have their own single rooms, three of which have an en suite toilet and there is one bed-sit, with its own kitchen and bathroom. Some service users do smoke in their rooms and all rooms have smoke alarms, which are connected to the Fire Alarm system. There are sufficient bathrooms, showers and toilets within the home. Four of the service users’ bedrooms were seen during the inspection. It was noted that one was very cluttered and that a number of electrical adaptors were in use. The Manager stated that all the electrical appliances were regularly checked and that regular fire checks took place. Oak House has a large, well-tended garden. There is a “training” kitchen, which contains two electric cookers, washing machines and tumble dryers. There is a planned maintenance programme in place and quotes are currently being sought for redecoration to the stairs and landing. It is also planned that the main kitchen will receive a major refurbishment. It was noted that several bathrooms looked “tired” and in need of sprucing up. It is recommended that bathrooms be added to the maintenance programme for the coming year. On the day of the inspection Oak House was clean and free of any offensive odours. There are policies in procedures in place with regard to housekeeping and for the control of infection. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 21 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): Standards 31, 32, 33, 34 and 35. Quality in this outcome area is adequate. There is an experienced and competent staff group in place, who understand their roles and responsibilities. The question of staff accessibility has been raised and this needs to be looked at so that service users and staff feel confident that service users’ needs are fully met. There are robust recruitment procedures in place, which protect service users. All documentation required by legislation needs to be available in staff files. Staff and service users benefit from a well-trained staff group. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All staff have job descriptions and those spoken to during the inspection were aware of their roles and responsibilities. One member of staff gave a good description of her role as a key-worker. Staff are given copies of the General Social Care Council Code of Conduct. Although the majority of the service users spoken to during the inspection said that the staff treated them well and listened to them, this was not borne out Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 22 one hundred percent by the returned surveys, or by all the service users. Of the returned surveys, 3 said that staff “always” treated them well, 3 said “usually” and 1 said “sometimes.” Asked if carers listened, 3 said “always”, 4 said “usually” and 1 said “sometimes”. One service user said that staff were “alright”, but that he didn’t always know when to ask a question, he said that sometimes “they say they’re busy”. Accessibility of staff was raised last year, by a different service user, who said that he wished staff could spend more time talking with the service users. It is recommended that staff accessibility be discussed with the service users and among the staff group and that, if necessary, the Registered Manager re-look at to the rota to ensure that there is sufficient staff time to meet the needs of the service users. The staff group are experienced and well qualified and take part in a number of relevant training courses, including equal opportunities, violence and aggression, Storm training (risk management) and disability awareness. 80 of the staff group are trained to NVQ level 2 or above. Staff rotas show that there are 2 support workers on duty from 8.00 a.m. until 6.00 p.m. each day. From 6.00 p.m. until 8.00 a.m. the next day there is one support worker on duty, who sleeps in overnight. There is an emergency call system in place, plus an “On Call” manager. All staff receive “lone worker” training, plus training on how to handle any violence or aggression. The Registered Manager’s hours are supernumerary. There is a cleaner on duty on 7 days a week. The files of a random sample of staff were seen at the inspection in order to check recruitment procedures. This check showed that there are robust recruitment procedures in place, which protect the service users. It was found that one staff file did not contain all those documents required by legislation. All did contain evidence of satisfactory Criminal Records Bureau and Protection of Vulnerable Adults checks. There is a training and development programme in place and all staff have annual appraisals, during which their individual training needs are assessed and recorded. A record of the individual training needs assessment must be available on each personal file. New staff receive induction training to Skills for Care specifications. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 23 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): Standards 37, 39 and 42. Quality in this outcome area is good. There is an experienced and well-qualified Manager in place and service users benefit from a home that is well run and administered. The views of service users are regularly sought and the results of surveys influence the home’s annual development plans. The health and safety of service users and staff are protected by the home’s policies and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is experienced, competent and well-qualified, having achieved the Registered Managers’ Award and the NVQ4 qualification in care. She is respected by the service users and staff. The Manager has a clear job description, to ensure that all the Standards listed in 37.3 of the National Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 24 Minimum Standards are met. The Manager periodically updates her skills by taking part in relevant training. There are good systems in place to ensure that service users’ views of the home are obtained and acted upon. During the course of the inspection a Consultation folder was seen, which contained recordings of discussions with service users about various aspects of the home. At present the Association are developing a stakeholder survey. Questionnaires will be sent out to service users, their representatives and all other stakeholders, including visiting health and social care professionals, to obtain their views of Oak House. Feedback received from these surveys will be used to inform the home’s annual development plan. During the inspection those service users who wished to were given the opportunity to speak with the Inspector and discuss their views of the home. A representative of the Registered Person visits the home each month and prepares a written report, a copy of which is sent to the Commission. There is evidence from staff files that regular training takes place in first aid, moving and handling and infection control. Staff are currently being put forward for training in food hygiene. The Registered Manager is aware that some staff are in need of updated fire safety training and this is currently being arranged by the Association’s Human Resources Department. Records show that fire alarm tests, emergency lighting tests and fire drills take place at the required intervals. The Association employ a Fire Auditor, who is in the process of updated the home’s current Fire Risk Assessment. Staff carry out a monthly health and safety inspection of the home (assisted by service users if they wish) and this includes a fire door seal test. Evidence was seen of the regular servicing of the boiler and of the gas safety check. The water system was tested for legionella in November 2006. Water temperatures, both in the tank and at outlets accessible to service users are regularly checked and recorded. All hazardous substances are stored securely and the home have an analysis of all products used. There are clear policies and procedures in place and risk assessments are carried out to ensure safe working practices. All new staff receive induction training to Skills for Care specifications and this includes training on safe working practice topics. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA34 Regulation 19 Schedule 4.6 18(1)(c) Requirement Staff files must contain all the documentation required by legislation. In order to ensure that all staff receive training appropriate to the work they perform, a copy of their individual training needs assessment must be kept on their files. Timescale for action 31/01/07 31/01/07 YA35 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 YA17 Good Practice Recommendations It is strongly recommended that the home re-consider the practice of discontinuing the use of the training kitchen during the evening. Service users should be given the opportunity to make drinks and snacks at any reasonable time. If this practice is in place because there is a lone member of staff on duty, the duty rota should be reconsidered. It is recommended that advice be sought from the Pharmacist regarding the administration of medication when away from the home. It may be possible for the DS0000020831.V322575.R01.S.doc Version 5.2 Page 27 2. YA20 Oak House 3. 4. 5. YA20 YA20 YA33 Pharmacist to supply the medication for these days in a separate container, thus avoiding the practice of secondary dispensing. It is recommended that the home compile a list of specimen staff signatures. It is recommended that when “as required” medication is not needed, this be indicated on the medication administration record sheet. It is recommended that staff accessibility be discussed with the service users and among the staff group and that, if necessary, the Registered Manager re-look at the rota to ensure that there is sufficient staff time to meet the needs of the service users. Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 28 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: 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. Extracts may not be used or reproduced without the express permission of CSCI Oak House DS0000020831.V322575.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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