Inspection on 16/01/06 for Oak House

This inspection was carried out on 16th January 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oak House 31/07/07

Oak House 17/06/06

Oak House 27/09/05

Oak House 21/02/05

Oak House 31/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Oak House 1 Draycot Road Surbiton Surrey KT6 7BL Lead Inspector Mohammad Peerbux Unannounced Inspection 16th January 2006 1:00pm Oak House DS0000013425.V276206.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 DS0000013425.V276206.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 DS0000013425.V276206.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Oak House Address 1 Draycot Road Surbiton Surrey KT6 7BL 020 8390 8206 020 8287 1950 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) Mental Aid Projects Mr Richard Weir Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Mental Aid Projects is a charitable organisation providing residential and day care services. The organisation currently offers residential care in one large home and four smaller homes in Surbiton. One of the aims of this is that varying degrees of support and independent living can be offered. A Registered Manager oversees all of the homes, however there are two designated House Leaders allocated to the smaller homes. The day-to-day running of the home is mainly the responsibility of the House Leader. Oak House provides accommodation for three adults who have a learning disability. A minimum of one staff is employed throughout waking hours. A staff member sleeps at the house and provides night time support if required. All service users are assigned a key worker, who supports them to plan activities and day programmes. They also provide an opportunity for service users to have a named person to discuss any issues, concerns or plans. Service users are supported to make use of local day services and colleges. Support with these and travel in the community is agreed on an individual basis. At the home, service users are supported to learn and develop domestic skills and are involved in household tasks. Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s second inspection for the year 2005/06. Some time was spent looking at the policies and procedures, talking to the house leader, manager and to one of the service user. A tour of the building was also carried out. They are all thanked for their time and assistance. Requirements and recommendations from the previous inspection were also discussed with the manager. Overall the home continues to provide a good standard of care. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose should be reviewed to describe staff skills and experience and how these meet the needs of service users, and the specific needs the service can meet .The Service User’s Guide also needs to include all the information as per regulation 5 of the National Minimum Standards. Contracts for service users need to contain all the information required under standard five and service users must receive feedback about the outcomes of their involvement and participation with regards to the day to day running of the home. Service users must be provided with comprehensive, accessible and up to date information, in suitable formats, about its policies, procedures, activities and services, and appropriate communication support. Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 6 There need to be a staff training and development programme which meets Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. A training needs assessment must also be carried out for the staff team as a whole, and an impact assessment of all staff development must be undertaken to identify the benefits for service users and to inform future planning. The home must develop a quality assurance system and seek the views of service users and other stakeholders by means of surveys and carry out an annual audit. 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 DS0000013425.V276206.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 DS0000013425.V276206.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): 1, 2 and 5 The Statement of Purpose and Service User Guide are inadequate and do not provide sufficient information for prospective service users to be clear about the services the home provides to meet their needs. The home is able to demonstrate that service users needs are being appropriately met however service users are not always aware of the services they are being offered as no signed contracts were in place. EVIDENCE: It was previously required that the Registered Provider must ensure that the Statement of Purpose is reviewed to describe staff skills and experience and how these meet the needs of service users, and the specific needs the service can meet and those it can’t, in consultation with service users, and a copy supplied to the Commission for Social Care Inspection (CSCI). The manager stated that this requirement remain oustanding and therefore it will be repeated. The Service User’s Guide has also not been reviewed to include all the information as per regulation 5 of the National Minimum Standards in line with requirement made at the last inspection and therefore this requirement remains. Since the last inspection there has not been any new admission to the home. However the manager was reminded to ensure that new service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 9 appropriate communication method and with an independent advocate as appropriate in line with a requirement made at the last inspection. It was previously required that the Registered Provider must ensure that the contract/statement of terms and conditions includes the rooms to be occupied, rules in place at the home (in agreement with the purchasing authority), arrangements for the review of the Service Users Plan, and makes clear the ninety day trial period. The manager stated that this has been met and that he will forward a copy of the contract to the Commission on the following day of the inspection. However this was not received and therefore this requirement will be repeated. Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 8 Service user’s care plans are comprehensive and include detailed information on the service users’ needs and personal goals. However these care plans will have far greater authority when service users are involved as much as possible in their development. EVIDENCE: It was previously required that the registered manager must ensure that service users care plans are drawn up after consultation with the service user, family, friends and an advocate where appropriate. There has been a review meeting of one of the service users at the beginning of January and there was evidence that the service user, his family, staff and care manager have been involved in the service user’s care planning process. The manager also stated that the service users would be having a monthly inhouse review to evaluate their needs. This will involve the service user and his key worker. The home is also introducing a support plan for each service user to enable new staff to meet their needs. Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 11 The house leader stated that service users are offered opportunities to participate in the day-to-day running of the home. They are encouraged to share their views through service user’s meeting. However the registered provider must ensure that service users receive feedback about the outcomes of their involvement and participation. The home must also provide service users with comprehensive, accessible and up to date information, in suitable formats, about its policies, procedures, activities and services, and appropriate communication support. Oak House DS0000013425.V276206.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The daily routines and house rules promote service users’ rights, and ensure equality and that all rights are enjoyed by service users. EVIDENCE: During the inspection there was only one service user at home. The house leader was observed to interact with the service user in a positive manner. There was awareness from the staff that the service users privacy and individual choice must be maintained. The service user was observed moving freely throughout the communal areas and choosing on occasion to spend time in his bedroom. Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 13 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): 21 The home has failed to establish an up to date record of the service user’s wishes at death thus the potential for making the wrong funeral arrangements exists. EVIDENCE: It was previously required that the Registered Provider must ensure that the wishes of service users regarding death and dying are recorded, with the involvement of other stakeholders including friends and family members as appropriate. The manager stated that this has yet to be achieved and therefore the requirement will be repeated. Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. EVIDENCE: The home has a detailed complaints procedure. A pictorial format of this procedure has been developed and provided to service users. It was previously required that the registered person must ensure a written record is kept and available for inspection of all complaints made about the operation of the care home and action taken is appropriately maintained from now on. There was no evidence that this has been met and therefore the requirement remains. There has not been any complain since the last inspection. Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 and 29 The overall impression when visiting this home is that it is homely, comfortable clean and hygienic and the staff successfully promote a family-like environment which contributes to the service users’ health and emotional wellbeing. EVIDENCE: There are adequate toilet and bathing facilities in the home. There is a bathroom on the first floor and a toilet on the ground floor. The communal space in the home consists of kitchen, bathroom and a large sitting room and a dining room that are well maintained and comfortable. There is a rear garden that can be accessed by the service users via the conservatory. Presently there are only two service users living in the home. No aids or adaptations have been deemed as necessary at this time for either of the service users. Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 16 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): 33,34,35 and 36 Care staff are not receiving supervision on a regular basis, which have an impact on the standards of care being provided to service users. EVIDENCE: The house leader stated that he has NVQ level 2 and NVQ level 3 qualifications. However he was not able to confirm if the other staff have NVQ qualifications or undertaking the course. Presently there are only one full time staff and one part time staff in post. The home also uses two bank staff on a regular basis. An immediate requirement was issued at the last inspection for the Registered Provider to ensure that any care worker who works with service users has received an appropriate CRB (Criminal Records Bureau) check, validating that the person has been vetted as being safe to work. This has been met. The house leader stated that he has not had any form of training since he started work in the home in May 2005. He was booked to attend a medication training last year. However this was cancelled by the body, which was providing the training due to limited number of places available. There were no training records available in the home. The registered manager must ensure that there is a staff training and development programme in place which meets Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. This was a Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 17 requirement from the last inspection and will be repeated. The registered manager must also ensure that a training needs assessment is carried out for the staff team as a whole, and an impact assessment of all staff development is undertaken to identify the benefits for service users and to inform future planning. Supervision records were not available again at the time of this inspection. The manager stated that he would forward copies of staff supervision records to the Commission however they were not received four days after the inspection. The Registered Provider must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. It is also recommended that staff have an annual appraisal in order to review staff performances against their job descriptions and agree career development plans. Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,40,42 and 43 The home’s providers need to evidence (in a Development Plan) that the home is meeting its aims and objectives and is being run in the best interests of service users. It also needs to have a business and financial plan to ensure the effectiveness, financial viability and accountability of the home. EVIDENCE: It was previously required that a quality audit system, including an annual development plan must be in place to assess whether the aims and objectives of the home have been met and the home must implement a professionally recognised quality assurance or ‘join up’ their own quality assurance tools into a cyclic quality assurance system. The manager informed that this has yet to be implemented and therefore the requirement will be repeated. Only a limited number of policies and procedures were available at the home at the time of this inspection. The registered manager must ensure that staff have access to up-to-date copies of, and understand and apply, all policies, Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 19 procedures and codes of practice. The registered manager must also ensure that service users have access to all relevant policies, procedures and codes of practice, in appropriate formats, and staff have tried to explain them to service users. All policies and procedures must be available in the home at all times. During the last inspection it was noted that the hot water temperature in the bathroom, toilet and kitchen were above the recommended level of 43 degrees. An immediate requirement was issued to address this issue. This was resolved successfully within the timescale. With regards to health and safety certificates the registered manager is required to ensure that records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate and are available in the home at all times. No business plan of the home was available at the times of inspection to confirm financial viability. The registered manager must ensure that a business plan is in place and a copy of which should be send to CSCI. This was a requirement at the last inspection and therefore remains. The manager stated that the business plan would be in place by April or May of this year. Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 3 28 3 29 3 30 X STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X 2 X X 2 2 X 2 1 Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 21 YES Are there any outstanding requirements from the last 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 4 Requirement The Registered Provider must ensure that the Statement of Purpose is reviewed to describe staff skills and experience and how these meet the needs of service users, and the specific needs the service can meet and those it cant, in consultation with service users, and a copy supplied to the Commission for Social Care Inspection (CSCI). (Previous timescale 30/11/05 not met). The Service Users Guide must be reviewed to include all the information as per regulation 5 of the National Minimum Standards. (Previous timescale 30/11/05 not met). The Registered Provider must ensure that the contract/statement of terms and conditions includes the rooms to be occupied, rules in place at the home (in agreement with the purchasing authority), arrangements for the review of DS0000013425.V276206.R01.S.doc Timescale for action 31/03/06 2. YA1 5 31/03/06 3. YA5 5 31/03/06 Oak House Version 5.1 Page 22 the Service Users Plan, and makes clear the ninety day trial period. (Previous timescale 30/11/05 not met). 4. YA8 24(3) The registered person must ensure that service users receive feedback about the outcomes of their involvement and participation with regards to the day to day running of the home. The home must provide service users with comprehensive, accessible and up to date information, in suitable formats, about its policies, procedures, activities and services, and appropriate communication support. The Registered Provider must ensure that the wishes of service users regarding death and dying are recorded, with the involvement of other stakeholders including friends and family members as appropriate. . (Previous timescale 30/11/05 not met). The Registered Person must ensure a written record is kept and available for inspection of all complaints made about the operation of the care home and action taken is appropriately maintained from now on. (Previous timescale 30/11/05 not met). The Registered Provider must ensure that there is a staff training and development programme which meets Sector Skills Council workforce training targets and ensures staff fulfil DS0000013425.V276206.R01.S.doc 31/03/06 5. YA8 24(3) 31/03/06 6. YA21 12 31/03/06 7. YA22 17 31/03/06 8. YA35 18 31/03/06 Oak House Version 5.1 Page 23 the aims of the home and meet the changing needs of service users. (Previous timescale 30/11/05 not met). 9. YA35 18(1)(C) The registered manager must ensure that a training needs assessment is carried out for the staff team as a whole, and an impact assessment of all staff development is undertaken to identify the benefits for service users and to inform future planning. The Registered Provider must ensure that formal supervision sessions are held with all care staff at least six times a year, and that these sessions are recorded and signed by both the supervisor and supervisee. (Previous timescale 30/11/05 not met). A quality audit system, including an annual development plan must be in place to assess whether the aims and objectives of the home have been met and the home must implement a professionally recognised quality assurance or join up their own quality assurance tools into a cyclic quality assurance system. (Previous timescale 30/11/05 not met). The registered manager must ensure that staff have access to up-to-date copies of, and understand and apply, all policies, procedures and codes of practice. The registered manager must ensure that service users have access to all relevant policies, DS0000013425.V276206.R01.S.doc 31/03/06 10. YA36 18 31/03/06 11. YA39 24 31/03/06 12. YA40 17 and Appendix 3 31/03/06 13. YA40 17 and Appendix 3 31/03/06 Oak House Version 5.1 Page 24 procedures and codes of practice, in appropriate formats, and staff have tried to explain them to service users. 14. YA42 17 and Appendix 3 The registered manager is required to ensure that records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate and are available in the home at all times. The Registered Provider must ensure that a business plan is available for inspection, demonstrating the financial viability and accountability of the home and send copies to CSCI. Previous timescale 30/11/05 not met). 31/03/06 15. YA43 25 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA36 Good Practice Recommendations It is recommended that staff have an annual appraisal in order to review staff performances against their job descriptions and agree career development plans. Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. Extracts may not be used or reproduced without the express permission of CSCI Oak House DS0000013425.V276206.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!