Inspection on 27/09/05 for Oak House

This inspection was carried out on 27th September 2005.

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 10 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 16/01/06

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 27 and 30 September 2005 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 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 Stationary 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 G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Oak House Address 1 Draycot Road, Surbiton, Surrey, KT6 7BL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8390 8206 Mental Aid Projects Mr Richard Weir Care Home 3 Category(ies) of Learning Disability (3) registration, with number of places Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21 February 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. One House Leader overseas Oak House and another small home, which is situated next door to Oak House. 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 G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2005/06. It was an unannounced inspection and took place over four and a half hours. Some times were spent looking at the policies and procedures, talking to the manager, staff and to some of service users. They are all thanked for their time and assistance. A tour of the building was also carried out. Service users spoken to stated that they were happy with the care being provided. Requirements and recommendations from the previous inspection were also discussed with the registered manager. Two immediate requirements were issued during this inspection. One was in regard to the hot water temperature being above the recommended level and the other was regarding Criminal Record Bureau check not being carried out on one of the member of staff. A follow up visit was carried out after the initial inspection and it was noted that the registered manager has taken steps to address these issues. What the service does well: Service users are very much the centre of attention in the home; all of them have a programme of day care. The home seeks to promote the independence of service users and ensure equality of service. All of the service users have resided at the home for many years and as a consequence are very much involved in running the home. Individual care plans are very comprehensive and headings include a pen portrait of the service user, weekly activities, health needs and communication skills to mention a few. The arrangements for health care needs of the service users is good, all service users are registered with a local General Practitioner, the home has the support of the local pharmacist for advice on medication. Staff members have access to a range of training courses, including NVQ’s to build on their skills to ensure that they are able to meet the service users assessed needs. Service users were observed to be treated with respect by staff and to have their privacy and dignity respected. Comments from service users were generally positive, with indication that staff is kind and helpful in meeting their care needs. Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 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 G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 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 standard(s) 1,2,3,4 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: The Registered Provider has compiled a Statement of Purpose outlining the aims and objectives of the home, and the facilities and services it provided. However 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 home has produced a Service User’s Guide and it is also available in pictorial format. However the Service User’s Guide must be reviewed to include all the information as per regulation 5 of the National Minimum Standards. The home has a preadmission procedure; prospective service users are able to visit the home on an individual basis. The registered manager stated that service users are only admitted to the home once a full assessment of their Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 9 needs; compiled by their care manager or other relevant person has been received. However it was noted that the one service user who has recently been admitted, did not have an assessment carried out by the home. The registered manager must ensure that new service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. It was clear from care plans sampled at random that service user’s needs are being met. Records revealed that service users are in regular contact with other health and social care professionals who regularly visit the home to check that assessed needs are being met. 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 registered manager confirmed that all prospective service users are encouraged to visit the home as often as practical, to encourage a familiarisation process with the premises, its location and the other service users and staff. Trial visits are available for meals and over night stays. There has been some progress in improving contracts between the home and the service users. However contracts did not state that all service users would have a three-month ‘settling in’ period of residence at the home. In addition contracts inspected did not contain all the information as required under standard 5.2. The home must accordingly amended service users contracts, as at present there is the potential for their rights to be reduced. Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 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 standard(s) 6,7,9 and 10 Care plans are comprehensive and include detailed information about service users’ needs, personal goals, wishes and risk assessments. Service users are involved in decision making about their lives, they participate and can take some risks so that they live as normal a life as possible. The home has a confidentiality policy in place, which ensure information is handled in the best interests of the service users. EVIDENCE: Each service user has an individual service user plan that details their needs and how staff should meet these needs. These plans were organised, appropriately detailed and well presented. Service User Plans detailed service users routines and abilities. However 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. The home reviews the care plan of the service user every six months. Documentary evidence was available to show that the annual review has taken place. The registered manager advised that the home is working on a new format for the individual plans Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 11 based on Person Centred Planning principles. Staff at the home have undertaken appropriate training in order to facilitate the care plans. The rights of service users to make decisions about their own lives is central to the ethos of the home, support and guidance is given in all areas to ensure that service users are making decisions which are in their best interests. From discussion with service users and staff no evidence of restrictions on service users were found. Risk assessments for service users were examined; they are integrated into the care plan. Potential risks are identified covering all aspects of their daily living both inside and outside the home. The home was able to demonstrate that this standard was met as individualised care plans were in place for each service user that referred to action required to minimise identified risks and hazards. It was previously required that the registered manager must ensure that risk assessments are in place for the times that service users are left alone in the home. These are now in place. The home has a confidentiality policy in respect of personal information held in relation to service users. General service user’s documentations (i.e. service user plan, medical appointments and reviews) are kept locked in the office. The staff on duty demonstrated a good knowledge of service users rights in relation to confidentiality. Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 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 standard(s) 11,12,13,14,15 and 17 Service users are encouraged to explore opportunities to enhance their quality of life as well as maintain and participate with friends and the local community, with the aim of maximum integration. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: The inspection findings indicated staff work very closely with the service users to develop independent living skills at the home. It was observed staff assisting users with making decisions about tasks, activities inside and out of the home. Evidence recorded in individual care plans also indicated staff offer support, advice and other input that help to enhance and develop independent living skills. The home is supporting service users to access appropriate activities through the activity programme. The service users access local parks, cafes, theatres, Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 13 local leisure facilities and shops. In addition to swimming, gym and library. The staff team are available to support service users while accessing community resources. Service users are actively encouraged to maintain links with their families and friends. The home has an ‘open’ visitor’s policy and simply recommends that visitor’s telephone to say they are coming to ensure there loved one will be available. Service users at the home are able to plan and prepare their own food with support. Mealtimes are reported to be flexible and service users are able to choose what they wish to eat on the day. Generally service users and staff eat together, although service users are able to eat alone if they wish. There is a pleasant conservatory with a dining table in the home. Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 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 standard(s) 18,20 and 21 Service users’ personal, physical and emotional health needs are being appropriately met and reviewed. This ensures that the service users’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Service users’ medication is also well managed to ensure maximised good health. The home has failed to establish and record the service user’s wishes at death. Thus the potential for making the wrong funeral arrangements exists. EVIDENCE: The findings indicated that service users are able to exercise some level of independence in their personal care needs with appropriate support from staff where needed. The overall impression gained from observing how service users live at the home, indicated a good culture of semi-independent living, with most users have reasonable control over their lives and support from staff where needed. However the Registered Provider must ensure that the home can demonstrate the benefit of discussing the completion of agreed chores with service users at their meeting, ensure that the privacy and dignity of service users is respected, support service users to influence key decisions at the Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 15 home including the recruitment of staff, and that service users receive clear information about the outcome of involvement and participation at meetings. Records examined showed that all medicines administered are recorded on Medicine Administration Record Sheets, which were up to date at the time of the inspection. Medication profiles and clear medication administration record sheets were seen in records sampled. Currently there are no service users who self medicate. It was previously required that the Registered Provider must ensure that a written policy for medication being taken out of the home is maintained in the home. This has now in place. None of the service users have their last wishes documented on their personal files. 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. Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 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 standard(s) 22 and 23 Arrangements for complaints and protection from abuse are well managed and ensure that service users feel listened to and safe. EVIDENCE: The home has a detailed complaints procedure. A pictorial format of this procedure has been developed and provided to service users. However 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. The home has adopted the Royal Borough of Kingston’s Suspected Abuse of Vulnerable Adults Joint Policy and also has an additional policy on protection of vulnerable adults and whistle blowing. Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 17 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 standard(s) 24,25,26 and 30 The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the service users’ health and emotional wellbeing. EVIDENCE: The home is a semi-detached property situated near Tolworth shops and facilities in a residential road. The neighbouring house, Cherry House, is also owned and managed by Mental Aid Projects. The gardens at the home are interconnecting, however service users are asked to respect each other’s privacy and must not use the connecting gate to enter the other home without first being invited. There is one bedroom on the ground floor and two on the first. The staff office and sleeping room is also on the first floor. There is no lift at the property and the main bathroom is on the first floor. There is a conservatory to the rear of the property. The bedrooms are decorated to reflect the individual personalities of the service users. It was previously recommended that each lockable bedroom has an override devise. The registered manager stated that the home has a master key that can open any lock of the bedroom’s door in emergency. Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 18 The inspection findings indicated the home provides adequate living and bedroom spaces for each service user. Some of the bedrooms were checked. They were decorated to a good standard. The rooms contained a variety of personal furniture and fittings that reflected the individual’s personality. The home is kept very clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34,35 and 36 The staff team at the home have a range of skills and ability, which appear to meet the needs of the service users. One concern was identified in regard to recruitment checks not being completed satisfactorily, which impinge on the safety and protection of service users being ensured. 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 registered manager stated that all staff have a job description in place. The job descriptions contain the main purpose, tasks, including household and administrative tasks staff are expected to perform and be responsible for. The home has copies of the General Social Care Council Code of conduct as recommended from the last inspection. It was previously recommended that the Registered Provider should ensure that staff are supported to achieve National Vocational Qualification in Care qualifications. The House Leader in post at present has NVQ level 2 and 3. Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 20 As part of the inspection process staff files were sampled at random and it was found that one member of staff was working without a Criminal Record Bureau check or a POVA check. An immediate requirement was issued. The Registered Provider must 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. It was previously required that the Registered Person must ensure that all records required in Schedule 2 are available on all staff working in the home. This still has to be achieved therefore this requirement will be repeated. Individual staff training profiles were not available for 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. Supervision records were not available for 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 G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,42 and 43 The home is generally managed well however the health, safety and welfare of service users and staff are not being promoted/protected and this potentially places them at risk. EVIDENCE: The registered manager Richard Weir oversees the management of four Mental Aid Projects’ residential homes. The day to day operations are managed by a House Leader .It was previously recommended that the Registered Provider should support the House Leader to achieve an NVQ qualification, incorporating some of the management aspects of their role. There is now a new house leader in post who has NVQ level 2 and 3. Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 22 The registered manager informed that service users meetings are held on a monthly basis to ensure that service users views are listened to. There is no formal quality assurance system in the home. 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 .The home must implement a professionally recognised quality assurance or ‘join up’ their own quality assurance tools into a cyclic quality assurance system. During the 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. 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. Oak House G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 23 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 2 2 3 3 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 x 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Oak House Score 3 x 3 2 Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x 2 2 G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 24 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 1 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 can’t, in consultation with service users, and a copy supplied to the Commission for Social Care Inspection (CSCI). The Service User’s Guide must be reviewed to include all the information as per regulation 5 of the National Minimum Standards. The registered manager must ensure that new service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 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 G53 S25763 OakHouse V196555 270905 stage4.doc Timescale for action 30/11/05 2. 1 5 30/11/05 3. 2 14 30/11/05 4. 5 5 30/11/05 Oak House Version 1.40 Page 25 5. YA6 15 6. YA21 12 7. YA22 17 8. YA34 19 9. YA35 18 10. YA36 18 purchasing authority), arrangements for the review of the Service Users Plan, and makes clear the ninety day trial period. The Registered Provider must ensure that service users care plans are drawn up after consultation with the service user, familiy, friends and an advocate where appropriate. 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 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. The Registered Provider must 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. 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 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 G53 S25763 OakHouse V196555 270905 stage4.doc 30/11/05 30/11/05 30/11/05 27/09/05 30/11/05 30/11/05 Oak House Version 1.40 Page 26 11. YA39 24 12. YA42 13 13. YA43 25 14. YA34 19 recorded and signed by both the supervisor and supervisee. 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 Registered Provider must ensure that the hot water temperature is always within recommended level. 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. The Registered Provider must ensure that all documentation listed in Schedule 2 is obtained from each staff member. 30/11/05 27/09/05 30/11/05 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. 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 G53 S25763 OakHouse V196555 270905 stage4.doc Version 1.40 Page 27 Commission for Social Care Inspection 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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