Inspection on 16/10/07 for Oakcroft

This inspection was carried out on 16th October 2007.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oakcroft 10/10/08

Oakcroft 26/02/07

Oakcroft 29/12/05

Oakcroft 11/07/05

Oakcroft 18/10/04

Oakcroft 27/04/04

Oakcroft 02/03/04

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

CARE HOME ADULTS 18-65 Oakcroft 8 Winston Rise Four Marks Alton Hampshire GU34 5HW Lead Inspector Craig Willis Key Unannounced Inspection 16th October 2007 09:45 Oakcroft DS0000034443.V347374.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 Oakcroft DS0000034443.V347374.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. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakcroft Address 8 Winston Rise Four Marks Alton Hampshire GU34 5HW 01420 563442 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) oakcroft@iliace.com ILIACE Limited Post Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th February 2007 Brief Description of the Service: Oakcroft is registered to provide care and accommodation to four people between the ages of 18 and 65 who have a learning disability. Each person has a single bedroom, with the use of two shared bathrooms. People share the use of a main lounge, dining room, kitchen and activity room. There is an enclosed garden to the rear of the home that people are able to access. The home has a car that people are able to use when there is a staff member on duty who is registered to drive. At the time of the report, CSCI were waiting for confirmation of fee levels, which was requested during the visit. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence used to write this report was gained from a review of the information the provider sent to the Commission for Social Care Inspection (CSCI) since the last visit. This information included incident reports sent to CSCI and an annual quality assurance assessment. A site visit to the home was made on 16 October 2007. During the visit the inspector met three of the residents and observed the interactions between residents and staff. The inspector also spoke with the manager, staff on duty and the regional manager. The communal areas of the building were viewed and documents relating to the running of the home were inspected during the visit. What the service does well: What has improved since the last inspection? Work continues to ensure the house is well maintained. New flooring has been laid in the dining room. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 6 The home now has a permanent manager, who was appointed in August 2007. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Oakcroft DS0000034443.V347374.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 Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are comprehensive assessments of people’s needs before they move into the home, which reassures people that the home will be able to meet their needs. EVIDENCE: The manager reported in the annual quality assurance assessment for CSCI that people have a full needs assessment before they move into the home. The records of one person who has recently moved into the home were inspected during the visit. This person had a comprehensive assessment, which was completed by the company’s placements team and the manager. The assessment was carried out in the person’s previous placement, which was his school. The assessment also involved input from relatives. The assessment covers all aspects of the person’s needs, including health, self help skills, academic skills, participation in activities, social skills, community skills, personal relationships and sexuality and challenging behaviour. Following this assessment a transition programme was put in place, involving visits to the home to meet with other people who live there and staff and to make choices about room décor and furniture. The manager reported that the placement would be formally reviewed at the end of a three month trial period. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good care planning and risk assessment systems, which supports people to make decisions about their lives and helps staff to provide the support that people need. EVIDENCE: The records of all four people who live in the home were inspected during the visit. People had a care plan, which set out how their assessed needs should be met. The care plans seen reflected the information that was included in the initial assessment. There was programme for regularly reviewing the care plans and it was clearly recorded where people’s needs had changed. Details of how people should be supported to make decisions are set out in the care plans, for example, through the use of objects of reference. A number of the objects of reference are kept in drawers by the front door, and used to support people to make decisions about the activities they take part in. People Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 10 spoken with during the visit said they were able to make decisions about the activities they take part in. Risk assessments have been completed for all people living in the home and include actions that should be taken to minimise the identified hazards. These assessments have been regularly reviewed and amended where necessary. Staff spoken with said they thought the information in care plans and risk assessments was accurate and helped them support people. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good support for people to take part in activities they enjoy and meet their lifestyle choices. EVIDENCE: People are supported to take part in a wide range of activities, including sailing, archery, gardening, attending a local activity centre and cookery. Each person has a programme of activities run through the Adults Continuing Education (ACE) service, which is operated by the company. People take part in activities in their local community, such as visits to the local pub and shops. People are supported to maintain contact with their friends and family, with staff providing support for people to visit family where necessary. People are supported to take part in various household jobs, such as cleaning their bedroom, preparing food for meals and shopping. Details of the support Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 12 that people need with these tasks are included in their care plans. During the visit one person was being supported to vacuum the lounge. The home has a planned menu, which provides a balanced and nutritious diet. People’s likes and dislikes are recorded as part of their care plans and alternative meals are offered if people want them. Mealtimes are flexible to fit round activities and snacks are available at any time. People spoken with said they liked the food. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s personal care is well met by staff who know what their needs are and people attend the health services they need. The errors in the medication systems do not demonstrate safe practice. EVIDENCE: Care plans contain details of the personal care support people need and how they prefer to receive it. People spoken with said they receive the support they need. People are supported to attend a range of health services, including GP, nurse, dentist, psychiatrist and specialist hospital appointments. Details of consultations are recorded, including any advice given by the practitioner. The manager reported that all of the people living in the home need support to administer any medication they are prescribed. Medication is securely stored Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 14 in a locked cupboard and most tablets are supplied in a monitored dosage system. A record is kept of medication coming into the home and returned to the pharmacist for disposal. All staff administering medication have received training. There was an incident in August 2007 when the wrong medication was administered to a person who lives in the home. Following this incident staff consulted with the person’s GP and took their advice, which was followed. The member of staff responsible received additional medication training and had to complete a re-assessment before they could administer medication again. During the visit it was noted that none of the medication administered to one person the previous evening had been signed for on the medication administration record. The manager checked with the member of staff, who assured him that the medication had been administered, but the records had not been completed. The manager and area manager said they would address the issue with the member of staff concerned. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems for dealing with complaints and protecting people from abuse. This gives people confidence any complaints will be taken seriously and responded to. EVIDENCE: The home has a complaints procedure, which is provided to all people living at the home and has been made more accessible in a pictorial format. People spoken with during the visit said they would talk to staff if they had a complaint and thought their complaint would be taken seriously. The manager reported in the annual quality assurance assessment that the home has not received any complaints in the last year. CSCI has not received any complaints about the home. Staff have completed training in safeguarding adults. Staff spoken with demonstrated a good understanding of the action they should take if abuse is witnessed, reported or suspected. There is a policy and procedure on safeguarding adults and the prevention of abuse. The home looks after money for all the people who live there. This is individually stored in a safe and records are kept of expenditure. Each person has a bank account in their name, with two senior managers as signatories. Bank statements were available. The records of two people’s money were checked and the cash held matched the balance recorded. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides a clean, comfortable and safe environment for people. EVIDENCE: All of the home’s communal areas were viewed during the visit. The home is maintained to a high standard, with good quality, domestic furniture and fittings. People living in the home have access to a lounge, dining room, art / activity room and kitchen. There is a planned maintenance and renewal programme and staff reported that the maintenance team responds quickly to requests. New flooring has been laid in the dining room since the last inspection. The manager reported that this was chosen by people who live in the home and is easier to keep clean. There are two bathrooms with showers on the first floor of the home. There is a large garden to the rear of the home, which people have been supported to maintain and grow vegetables. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 17 The home has a separate, domestic laundry that is situated in a utility room next to the kitchen. There are procedures in place to ensure that laundry is not taken through the kitchen whilst food is being prepared. The home is clean throughout and there are no offensive odours. Hand washing facilities are suitably situated in the kitchen, laundry, toilets and bathrooms. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff receive good training, which helps them to meet people’s needs. Staff are generally well checked before they start work, although ensuring references are obtained for all staff would make the recruitment checks more robust and help to ensure people are protected. EVIDENCE: The manager reported in the annual quality assurance assessment for CSCI that two of the staff have achieved the National Vocational Qualification (NVQ) at level 2 or above and four are currently completing the award. The manager reported in the annual quality assurance assessment for CSCI that all staff who have worked in the home over the last twelve months have had satisfactory pre-employment checks. The files of three members of staff were checked. All three had a Criminal Records Bureau enhanced disclosure and Protection of Vulnerable Adults list check. Two had two written references, however, one member of staff had only one reference and this was not from their previous employer. The records indicated that the reference from the previous employer had been requested, but not received. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 19 The home has an on-going training programme and staff reported that they receive good training, which helps them meet people’s needs. Staff training records indicated they had completed an induction and courses in medication administration, first aid, safeguarding adults, food hygiene, strategies for crisis intervention and prevention, moving and handling and fire safety. The manager completes a monthly analysis of training, which is used by the company to plan courses that are needed. These records indicated that people had been booked onto training courses where gaps had been identified. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home now has a permanent manager, however, the lack of formal quality assurance systems does not ensure that shortfalls in the service are identified and improvements planned. EVIDENCE: The manager has been in post since August 2007 and reported that he will be submitting an application for registration to CSCI by the end of October 2007. The manager has over five years experience supporting people in social care and has started work on the National Vocational Qualification level 4 in care and the Registered Manager’s Award. Staff spoken with said they received good support from the manager. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 21 A regional manager visits the home every month to assess the quality of the service that is being provided. Reports of these visits are made and sent to the manager, including any actions that are required. The company has recently employed a quality assurance manager, who is currently completing a ‘health check’ of all their services. The results of these audits will be used to write a development plan. The manager reported that there is currently not a system for formally surveying people who live in the home, their relatives and other stakeholders about the quality of the service that is provided. The regional manager said he intends to put some interim measures in place while the company’s systems are being developed. The home has previously had a set of annual development objectives. These are now out of date and the manager reported he planned to write a new plan, with input from people who live in the home and staff. The manager reported in the annual quality assurance assessment for CSCI that the electrical system, portable electrical equipment, fire detection and fighting equipment, heating and gas system are regularly serviced and maintained. These records were inspected during the visit and while most were in place, there was no record that the fire fighting equipment and emergency lighting had been tested and checked by staff since August 2007. The manager said he would ensure that these tests were carried out. Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 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 2 X 3 X 2 X X 2 X Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation 19 (1) Requirement The registered person must ensure that two written references are obtained for staff before they start work in the home. Timescale for action 30/11/07 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 Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oakcroft DS0000034443.V347374.R01.S.doc Version 5.2 Page 25 - 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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