Inspection on 17/06/06 for Oak House

This inspection was carried out on 17th June 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 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 7 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 16/01/06

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 Michael Stapley Unannounced Inspection 17th June 2006 09:30 Oak House DS0000013425.V298938.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 DS0000013425.V298938.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 DS0000013425.V298938.R01.S.doc Version 5.2 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) The Fircroft Trust Mr Richard Weir Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 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.V298938.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home was inspected under the National Minimum Standards Care Homes for Younger Adults. The inspection took place over one day on 17th June 2006. The home was represented by the Registered Manager, Mr Richard Weir and support staff who all contributed to the inspection process. The manager is supported by Kay Harris, the chief executive of the Fircroft Trust the charity that manages the home. She too is very experienced and well qualified to support the manager in his day to day management of the home. Records examined included service user plans; care manager needs assessments and risk assessments, medication records, complaints, staffing records, health and safety and fire records. Previous requirements and recommendations were discussed with the registered manager who will be sending an action plan to the commission as agreed at the time of the inspection. What the service does well: Service users are supported by staff to peruse their individual hobbies and interests. Systems are in place to ensure that the service users are able to participate in the day to day running of the home. The home has a written and recorded agreement with each service user concerning the daily tasks within the home. The home is a small family home setting and staff endeavours to maintain this atmosphere of ordinary living, on an ordinary street within the local community. Oak House DS0000013425.V298938.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. Oak House DS0000013425.V298938.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 DS0000013425.V298938.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. The home provides good information and introduction opportunities for prospective service users to make an informed choice about moving to the home. Contracts between the home and the service users contain all the information required under standard five thus ensuring the rights of the residents of Oak House. Staff at the home have access to a wide range of training programmes thus enabling them to offer an effective care programme for service users. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a preadmission procedure; prospective service users are able to visit the home on an individual basis. Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. All of the service users at Oak House have lived at the home for some time and in discussion with the registered manager it was evident that assessment is on going and is seen as very much part of the care plan. Personal Care plans which are gradually being introduced are based on the home’s individual system which is an in depth assessment of all aspects of service users personal care, social, recreational and emotional Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 9 needs. The home carries out internal six monthly reviews where information is up dated and care plans changed as appropriate. There are also yearly reviews carried out with the service users, their families and other professionals as appropriate. The manager advised that all service users have access to an advocate. The home has a reasonable training programme including NVQ training. The training programme includes first aid, health and safety, medication, person centred care plans and fire awareness training. A requirement was made at the last inspection 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 cant, in consultation with service users, and a copy supplied to the Commission for Social Care Inspection (CSCI)” The home has completely reviewed its Statement of Purpose to include all the above information. This requirement has therefore now been met. A further requirement was that “The Service Users Guide must be reviewed to include all the information as per regulation 5 of the National Minimum Standards” The home has reviewed the above document to include all the information under regulation 5. This requirement has therefore now been met. A further requirement was 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 home has reviewed service users contracts and those that were inspected now contained all the information as required under standard 5.2. thus ensuring service user’s rights. This requirement has therefore now been met. Oak House DS0000013425.V298938.R01.S.doc Version 5.2 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, 7, 8 and 9. Service user care plans contain all the information required as per standard six. Staff at the home have all the information they require to satisfactorily meet the needs of the service users. Service users have individual risk assessments and risk management strategies carried to enabling them to participate in activities in the home and in the community with appropriate support. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user individual care plans are comprehensive and contain all the elements of standard six. Care plans contain a pen portrait of the service user, weekly activities, health needs and communication skills. Service users and their respective families are involved in drawing up such plans as outlined in standard 6.6. In addition service users have a key worker who is responsible for service user’s day to day care and for completing a monthly report which highlights areas of development and particular need. It is suggested that Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 11 service users could have their own personal file which they could keep and refer to. The home is very service user focused. Service users are encouraged to become far more involved in the home. House meetings that take place every four weeks are used as a communication tool to empower service users. Service users files sampled at random all had individual risk assessments and risk management strategies, although some of the later require review. Service users are encouraged to make their own decisions within the context of risk assessment wherever possible. All service users have individual choice and the home provides an independent advocate where desired. There were two requirements made under standard YA8 at the last inspection “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” and “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” As stated above House meetings are used as a tool to empower service users. In addition the manager or house leader gives feedback to service users of their involvement in the day to day running of the home. The inspector was further advised that the home has introduced quarterly parents/carers meetings which act as a forum for discussion and feedback. In addition the inspector noted that all the homes main polices that were relevant to service users are in a suitable format for service users, these service users guide, complaints and chores service users are expected to undertake. Both of these two requirements have therefore now been met. Oak House DS0000013425.V298938.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. The daily routines and house rules promote service users’ rights, and ensure equality and that all rights are enjoyed by service users. Service users are given opportunities to engage in age appropriate activities with an emphasis on using community-based facilities. Dietary needs are catered for and a balanced diet is provided, to ensure a nutritious diet based on personal preferences. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 user’s 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.V298938.R01.S.doc Version 5.2 Page 13 The home supports service users to access appropriate activities such as swimming, sports and leisure activities and making use of the library. In addition service users have access to local parks, cafes, theatres and shops. One of the two service users is able to travel independently while the staff team are available to support other service users to access community resources. Service users spoken to stated that they enjoyed the activities on offer at the home. Service users at the home have an annual holiday; the inspector was advised that arrangements are being made for some of the service users to go to Butlins in Bognor Regis. Parents, relatives and friends are encouraged to visit the home whenever possible. Service users have access to a wide range of educational facilities and the manager advised that service users have access to the homes computer. It is suggested that the home consider having an internet connection. This would clearly be of benefit to service users as it would increase their range of leisure and educational opportunities. Weekly menus were constructed with the aid of the service user’s personal choice, advice from service user’s families and the experiences of the staff. One service user said that they enjoyed what they had to eat at the home. The home has access to its own vehicle and also uses community transport. Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 14 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): 18, 19, 20 and 21. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ medication is well managed to ensure good health. 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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health records are maintained for each service user. Service users record examined during the inspection demonstrate that the service user had access to routine health checks and specialist health care. Significant events and accidents are recorded and monitored. The staff team at the home keep a central record of incidents as well as an individual record on service user’s files. Staff members monitor service user’s health and maintain up to date records. All of the staff team have now completed accredited medication training. Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 15 The pharmacist visits the home on a regular basis. All requirements and recommendations from the inspection of 13th March 2006 have been complied within laid down timescales. The manager has introduced a weekly medication audit following concerns expressed by the Inspector at the last inspection of Maple Lodge which is a home also managed by the Fircroft Trust. This form has been commended by the pharmacist from Boots the chemist and is now being used in other registered homes in the area. All other medication records, including MAR sheets and service user profiles were correct at the time of the inspection. In addition the home keeps a list of specimen signatures for those staff that administer medication. A requirement from the last announced inspection that the wishes of service users regarding death and dying are recorded has still not been complied with. The manager advised that he had drawn up a template for this to be recorded although the home was finding this to be an extremely sensitive matter to deal with. The home has decided to meet with the families of the two current service users to address this matter. The inspector noted that a date had been made to meet with one of the service users families. At present as there are no funeral arrangements held on file there is the potential for making incorrect funeral arrangements for service users. The registered person must ensure this requirement is met without further delay. This requirement has therefore been repeated although the inspector acknowledges that the home had made progress in meeting this standard. Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 16 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 and 23. There is a complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a detailed complaints procedure. A pictorial format of this procedure has been developed and provided to service users. The Registered Manager said that no complaints have been made to the home since the last inspection. There are also policies and procedures in place regarding the protection of vulnerable adults. All staff has received appropriate training in Vulnerable Adult Abuse. The staff team are aware of the action they must take if they need to report an incident. A requirement was made at the last inspection 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” As outlined above the homes has a Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 17 detailed complaints procedure and a complaints book which was seen during this inspection. This requirement has therefore now been met. Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 18 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): 24, 25, 26, 27, 28, 29 and 30 Service user’s bedrooms provide privacy and reflect individual interests and preferences. The home is homely, bright and clean with the necessary adaptations in place, thus providing the service users with safe, comfortable surroundings that meet their needs. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 19 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. There have been some improvements in the décor of the home since the last inspection although some areas are looking shabby and are in need of decoration. The registered manager stated that the home had programme of redecoration and maintenance which was seen during this inspection and he advised that he will be discussing this programme with the managing company. In addition furnishing, fixtures and fittings are to be purchased as required. There is also a small garden at the rear of the home. Bedrooms viewed provided sufficient with suitable furniture. All areas of the premises viewed were clean and free from offensive odours. Systems are in place for controlling the spread of infection. The home has thermostatic valves fitted to the bath to avoid any scalding accidents. The temperature of the water is taken and duly recorded. Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 20 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, 34 and 35. The staff team at the home have a range of skills and ability, which appear to meet the needs of the service users. The staff team have all had Criminal Records Check, as a safeguard to offer protection to the homes service users. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers reasonable training opportunities to staff at all levels within the home, although staff would benefit by taking specialist training courses such as that offered by BILD for staff who work with service users who have a disability. New members of staff complete an induction programme covering various subjects including health and safety, fire drills, and introductions to service users and other staff. The induction programmes are signed, dated and kept on staff files. Criminal Records Checks are completed before a new member of staff can begin work in a home. Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 21 The home has a small but experienced staff team consisting of house leader and support worker in addition to regular care bank staff. The registered manager of Maple Lodge a registered home managed by the same managing company as Oak House has overall responsibility for the home. He is a very experienced and well qualified manager. The registered manager offers professional support to the house leader and support workers through regular supervision which is now in line with the standard. There is always one member of staff on duty who also undertakes sleeping-in duties. There are suitable on call arrangements in place in case of an emergency. There were three requirements made under this section of the report at the last inspection “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 the aims of the home and meet the changing needs of service users” • The inspector evidenced a training plan for Oak House. In addition the registered manager has introduced an annual appraisal for all staff. The training needs for staff are identified during the annual appraisal and duly recorded following which arrangements are made for staff to attend such training. This requirement has therefore now been met. “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. • As outlined above all of the staff who work at Oak House have an identified training plan. This requirement has therefore now been met. “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. • The inspector noted that all staff at Oak House is now receiving supervision at least six times each year. The supervision format is comprehensive and contains all elements of standard 36.4 Records seen during the course of this inspection were signed and dated by the registered manager and member of staff. This requirement has now been met. Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 22 Oak House DS0000013425.V298938.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The management of the home appears to be open and transparent with clear lines of accountability, which is aimed at ensuring the well being of the service users. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager offer support and supervision to the support workers at the home. There were good support mechanisms in place and the manager meets with the chief executive of the Fircroft trust to discuss any issues concerning the home, efforts are made to meet any concerns or improve the service. The home has an annual development plan and business plan for 2006-07, which was available for inspection. The managing company ensure all records are in place by completing monthly regulation 26 reports. Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 24 Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, fire records, staff and service user’s case files, medication records. Fire drills are up to date and a fire risk assessment had been completed. The residents are beginning to benefit from a stable staff team and a continuity of approach this generates. However for residents and their stakeholders these developments need to be consolidated and built on in order for them to be confident that their best interests are safeguarded, their views are taken into account and the home is well managed. The system for consultation with service users, families, stakeholders and other interested parties is good. The quality assurance system includes relatives, staff and outside professional questionnaires. The registered manager explained he was in the process of developing service user questionnaires in a suitable format. When these had been finalised the results will be collated and any issues from these and other questionnaires will be addressed. The home will need to evidence that the results of the surveys are published and acted on for the benefit and wellbeing of the service users at the home. There were four requirements made under this section at the last inspection 1. “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” • This requirement has been partially met given that relatives and professionals have been sent questionnaires and some feedback has been received by the home. As outlined it remains for the home to seek the views of service users, collate the responses and decide how to address any issues from all of the responses received. 2 and 3. “The registered manager must ensure that staff have access to up-todate copies of, and understand and apply, all policies, procedures and codes of practice” and “The registered manager must 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 were available for inspection at the time of this inspection. All policies and procedures that are relevant to service users are now in a suitable format including complaints, service user guide and details of chores service users are expected to undertake. This requirement has therefore now been met. 4. “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” Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 25 • All certificates in respect of health and safety were evidenced during the course of this inspection. This requirement has therefore now been met. 5. “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” • A business plan was sent to the Commission for Social Care Inspection prior to this inspection. This requirement has therefore now been met. Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 X 4 X 5 3 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 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 3 X 2 3 X 2 3 Oak House DS0000013425.V298938.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES. 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. 4. Standard YA6 YA21 Regulation 15 Requirement Timescale for action 31/08/06 31/08/06 3. YA24 4. YA35 5. YA39 The registered person must ensure all service users have a person centred care plan. 12 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. . (This requirement was partially met as at 17/06/06 16(2)(a)(ii) The registered provider must ensure the home has appropriate facilities for communication by facsimile transmission. 18(1) The registered person must ensure that all staff undertake disability equality training, race equality and anti-racism training. 24 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 DS0000013425.V298938.R01.S.doc 31/07/06 31/08/06 31/08/06 Oak House Version 5.2 Page 28 6. 7. YA39 YA42 24(1) 26 assurance or join up their own quality assurance tools into a cyclic quality assurance system. (Partially met as at 17/06/06) The registered person must ensure that an internal audit takes places at least annually. The registered provider must ensure that monthly visits are made to the home and a report sent to the commission and registered manager. 31/08/06 31/07/06 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.V298938.R01.S.doc Version 5.2 Page 29 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. 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