Inspection on 23/11/05 for Oak House

This inspection was carried out on 23rd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oak House 12/12/06

Oak House 10/03/06

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 Announced Inspection 23rd November 2005 08:30 Oak House DS0000020831.V258213.R01.S.doc Version 5.0 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.V258213.R01.S.doc Version 5.0 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.V258213.R01.S.doc Version 5.0 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.V258213.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2005 Brief Description of the Service: Oak House provides residential accommodation for 12 adults who have a mental disorder. The home aims to assist its service users to live independently in the community. Service users and staff at the home have close links with the mental health multi disciplinary team. The accommodation at Oak house is over three floors and there is no lift. All bedrooms are single and three have an en suite facility. There is one bedsit, with a kitchen area. There are ample communal areas, including a conservatory. To the rear there is a large, well-tended garden. Service users have the use of a “training” kitchen in which they can prepare and cook their own meals and do their laundry. Oak House DS0000020831.V258213.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, carried out on a weekday between 8.30 a.m. and 6.30 p.m. Prior to the inspection the home forwarded a Questionnaire to the Commission. In addition service users and their representatives were asked to complete Comment Cards. Six service users and one relative were spoken to during the inspection. A tour was made of the building. The Support Plans of five service users were seen and various documents and certificates were inspected. At the last inspection, in February 2005, the home was given two statutory requirements. One of those has now been met. A further three requirements were made at this inspection. What the service does well: What has improved since the last inspection? Although there have been some problems with medication (see below) the home has taken steps to ensure that, as far as possible, these do not occur again. The new procedure for a daily audit has tightened up the system and improved staff awareness. There is an ongoing programme of redecoration and refurbishment of the premises and more is planned for the next few months. Service users have been fully involved in choosing furniture and colour schemes. All the recommendations of the Fire Officer have now been met and the home are about to introduce a Fire Safety Emergency Plan. Oak House DS0000020831.V258213.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Oak House DS0000020831.V258213.R01.S.doc Version 5.0 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.V258213.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home’s own assessment procedures are comprehensive, but there have been recent occasions when they have not obtained a Care Management Assessment. Without a full, professional assessment the home may not be fully aware of the person’s needs. EVIDENCE: The assessments and support plans for 3 service users were seen at the inspection. The service users had moved to the home within the last six months. All three had been referred through Care Management, but the home had not received a Care Management Assessment for any of these service users. There was evidence that the home had carried out its own assessment, including a risk assessment, but in order that a full picture can be gained of the person’s needs, a copy of the Care Management Assessment must be obtained by the home prior to a new admission. Following assessment, the registered manager must write to the service user confirming that home is able to meet the person’s needs. Each service user has a Support Plan, which is based on assessment information. Oak House DS0000020831.V258213.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10. There are comprehensive Support Plans in place, which ensure that service users participate in planning and reviewing their agreed objectives. Service users confirm that they are encouraged to make decisions about their lives. Service users are able to take risks, as part of their independent lifestyle, but steps are taken to minimise risk. The home is currently working with the Primary Care Trust to ensure an appropriate policy with regard to confidentiality. EVIDENCE: The Support Plans of 5 service users were seen. All were clear and comprehensive and contained details of the person’s individual needs and agreed objectives. The Support Plans had been signed by the service user, as had the records of regular reviews of the Plan. The Plans clearly show that service users are involved in their care planning. Service users spoken to during the inspection confirmed that they were aware of their Support Plans and felt that they were fully involved in their development and review. There are clear risk assessments, which are also agreed by the service users. All of the current service users are English speaking, but Support Plans can be made Oak House DS0000020831.V258213.R01.S.doc Version 5.0 Page 10 available in alternative languages and large print if required. There is a key worker system in place. During the inspection service users confirmed that they were encouraged to make decisions about their daily lives. An Advocacy Service is available locally if needed. All service users manage their own finances and receive advice with regard to budgeting. Some request that some monies are kept on their behalf in safe keeping in the home, and appropriate records are kept. The registered manager does not act as agent or appointee for any of the service users. The home has a Missing Person Procedure in place. Strategies to minimise risk are recorded and regularly reviewed. Oak House has a Confidentiality Policy, details of which are published in the Statement of Purpose. There was evidence at the inspection that service users’ records are accurate, secure and confidential. As at the last inspection, the home must develop a statement on confidentiality to its partner agencies, setting out the principles governing the sharing of information. The inspector was informed that this was currently being developed with its partner agencies. Oak House DS0000020831.V258213.R01.S.doc Version 5.0 Page 11 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): 13 Service users take advantage of a number of local facilities and are encouraged by staff to make links with the community to enhance their social and educational opportunities. EVIDENCE: Service users make use of a number of local facilities, including shops, the library, cinema, the Art Gallery, leisure centres and pubs. Some attend a Men’s Group. A group of service users attend a local Service User Network Disco. The majority of the time public transport is used. The registered manager and Support Workers are aware of the service users’ rights of access to public facilities under the Disability Discrimination Act 1995. All service users are on the electoral register. Staff time with service users during activities outside the home is regarded as part of their duties, although some choose to attend in their own time. Oak House DS0000020831.V258213.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. 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 systems for medication administration are good, but a recent maladministration has illustrated the need for ongoing refresher training and audits. EVIDENCE: All service users take care of their own personal care. Where “reminders” are needed, these are stated in the service user plan and dealt with discreetly. All service users spoken to confirmed that they were able to get up and go to bed when they wished. The registered manager stated that it is difficult for service users to have a choice of which staff work with them, given such a small staff group. Specialist support is provided by visiting healthcare professionals, such as community psychiatric nurse, occupational therapist, social worker and psychologist. The home operates a key worker system. Oak House DS0000020831.V258213.R01.S.doc Version 5.0 Page 13 Service users are able to choose their G.P. and 5 local practices are currently 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. All staff are shortly to undertake a distance learning course on Health and Nutrition. The home have clear policies and procedures for dealing with medicines. It is recommended that a copy of these documents is kept in the medical room. All service users have a lockable facility in their rooms in which to keep medication if they are self-administering. All service users who self-administer do so after a multi disciplinary assessment. Service users’ consent to medication is obtained and recorded on their Support Plans. Since the last inspection the home has once again experienced an incident of maladministration. This has been appropriately dealt with and a daily audit has been put into place to minimise the risk of any recurrence. Clear records are kept of all medicines received, administered and leaving the home. No Controlled Drugs are used at present, but appropriate systems are in place. Apart from one, who is registered to commence a course in November 2005, all staff who administer medication have received accredited training. If staff are concerned about a change in the condition of a service user, which may be the result of medication, prompt assistance is sought from the Consultant Psychiatrist or Community Psychiatric Nurse. An inspection of a random sample of medicines and accompanying records sheets showed that in two instances a record had been changed by sticking a piece of paper of the entry. This must not take place. If a mistake is made, the error must be crossed out by a single line. Pencil must not be used on records. Oak House DS0000020831.V258213.R01.S.doc Version 5.0 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 The home have a comprehensive complaints procedure and service users feel that their views are listened to an acted upon. EVIDENCE: There is a comprehensive complaints procedure in place. Recently the home have developed a system for examining complaints by looking at trends in complaint making. Service users spoken to during the inspection said that they knew who to talk to if they wished to make a complaint and that they were confident that complaints would be dealt with. Discussion took place with regard to an anonymous complaint received by the Commission. This complaint had subsequently been comprehensively investigated by the Company and was not upheld. Clear records are kept of any complaints made. Oak House DS0000020831.V258213.R01.S.doc Version 5.0 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): 24, 25, 27, 28 and 30. Although it is an older property, Oak House is generally well maintained and provides warm and comfortable accommodation. 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. Service users are currently being consulted about the next redecoration and refurbishment, which will include new furniture, curtains and carpets. Oak House DS0000020831.V258213.R01.S.doc Version 5.0 Page 16 Service users spoken to were all very satisfied with their accommodation. One said it was like being “in a hotel”. The Fire Officer 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 bedsit, with its own kitchen and bathroom. The majority of the rooms were seen at the inspection and all were in generally good order. 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. Oak House has a large, well tended garden. There is a “training” kitchen, which contains both gas and electric cookers, washing machines and tumble dryers. Staff are provided with a staff sleeping in room, with separate toilet and shower. On the day of the inspection the home was clean, warm and free of any offensive odours. Service users do their own laundry in the “training” kitchen, which has two washing machines and two tumble dryers. There are separate hand washing facilities in both the “training” kitchen and the main kitchen. Floor finishes in both rooms are impermeable. There are procedures in place with regard to housekeeping and a clear policy on infection control. Oak House DS0000020831.V258213.R01.S.doc Version 5.0 Page 17 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): 34 and 35. There are robust recruitment procedures in place to protect service users. The arrangements for the induction of staff are good and there are excellent opportunities for ongoing training in relevant areas. EVIDENCE: The files of two recently recruited members of staff were seen at the inspection. These showed that the home has robust recruitment procedures in place and that no one is employed at the home until the appropriate documentation and satisfactory checks have been received. All potential new staff meet with the service users prior to their interview. Service users have the opportunity to ask them questions and feedback to the interviewing panel. All staff are given copies of the General Social Care Council Code of Conduct. Copies of statements of terms and conditions are kept on individual files. There are no volunteers employed at the home. There is a training and development programme in place for the home and a dedicated training budget. The file of a recently recruited member of staff showed evidence of thorough induction training to Skills for Care specifications. Staff took part in Equal Opportunities training in May 2005 and all staff are to participate in a distance learning training course on Equality and Diversity. All staff have individual training and development assessments and profiles. A number of relevant courses in the needs of people with mental health problems are offered by the Joint Adult Services (Primary Care Trust, Social Services and local Colleges). Oak House DS0000020831.V258213.R01.S.doc Version 5.0 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 and 42. There are good systems in place for seeking the views of service users, their representatives and visiting social and healthcare professionals. Service users feels their views are listened to and acted upon. There are policies and procedures in place to protect the health and safety of both service users and staff. EVIDENCE: At the time of the inspection the home were not complying with Regulation 26 of the Care Homes Regulations. There was no evidence that regular monthly visits had been carried out by a representative of the Registered Providers. The last recorded visit was on 26th October 2005, the one before that being June 2005. Copies of such reports must be forwarded to the Commission each month. Service users’ views of the home are sought on a regular basis and there are regular Service users’ meetings. Service users took part in a Participatory Appraisal exercise and an Action Plan for the home resulted from this. A quarterly newsletter is published. Feedback about the home’s performance is sought from a number of visiting professionals. Policies, Oak House DS0000020831.V258213.R01.S.doc Version 5.0 Page 19 procedures and practices are regularly reviewed. Service users’ development plans are discussed at review meetings and recorded in their care plans. A random sample of staff files showed that regular staff training takes place in moving and handling, fire safety and first aid. The home have had difficulty in accessing Food Hygiene training. Staff have recently completed a distance learning course in infection control. Records seen show that fire alarm tests, emergency lighting tests and fire drills take place at the required intervals. The home now have in place a Fire Safety Emergency Plan, which is to be introduced to staff at the next team meeting. The annual gas safety check was carried out in June 2005 and the 5 year electrical check in November 2005. The home recently commissioned a water hygiene survey and risk assessment and from January 2006 will have their own Water Safety Monitoring Record in place. Water temperatures at outlets accessible to service users are tested on a regular basis. There are window restrictors on all windows above ground floor level. The management of the home have recently been looking at the security of the building and are in the process of obtaining quotes for a security system. Full details are kept of all cleaning materials used, in accordance with COSHH regulations. There is an Accident Book in place and the home are shortly to commence an Incident Trend Analysis. There is a statement in place regarding responsibilities for maintaining safe working practices. Induction training includes safe working practice topics. Oak House DS0000020831.V258213.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 4 X 3 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 3 3 N/A 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Oak House Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X 4 X X 3 X DS0000020831.V258213.R01.S.doc Version 5.0 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 YA2 Regulation Requirement Timescale for action 23/11/05 2 YA2 3 YA10YA10 4 YA20 14(1)(a)(b) The home must not admit any new service user until they have obtained a copy of the Care Management Assessment. 14(1)(d) Following assessment, the 23/11/05 registered manager must write to the service user confirming that the home can meet the person’s needs. 12(4)(a) The home must provide a 28/02/06 statement on confidentiality to its partner agencies, setting out the principles governing the sharing of information. (It is understood that such a statement is currently being developed with the Primary Care Trust). (Previous requirement of 30/06/05 not met). 13(2) Staff must not cover mistakes 23/11/05 on medication administration record sheets with sticky labels. Pencil must not be used on these records. Oak House DS0000020831.V258213.R01.S.doc Version 5.0 Page 22 5 YA39 26 A representative of the Registered Persons must visit the home each month and prepare a report on the conduct of the home. A copy of this report must be forwarded to the Commission. 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Oak House DS0000020831.V258213.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oak House DS0000020831.V258213.R01.S.doc Version 5.0 Page 24 - 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. 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