Inspection on 09/01/07 for Oakdene Care Providers

This inspection was carried out on 9th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oakdene Care Providers 11/11/08

Oakdene Care Providers 17/07/07

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

CARE HOME ADULTS 18-65 Oakdene Care Providers Oakdene 6 Berwick Road Shrewsbury Shropshire SY1 2LN Lead Inspector Deborah Sharman Key Unannounced Inspection 9th January 2007 09:45 Oakdene Care Providers DS0000067573.V316087.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 Oakdene Care Providers DS0000067573.V316087.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. Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakdene Care Providers Address Oakdene 6 Berwick Road Shrewsbury Shropshire SY1 2LN 07855 795 239 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) Ms Caroline Edge Mr Stafford Andrew Jones Ms Caroline Edge Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection None. Brief Description of the Service: Oakdene is a five bedroom Edwardian town house within walking distance of Shrewsbury town centre. The property has been completely renovated to provide modern and homely domestic style accommodation for mobile young female service users with mental health needs. The Provider took the decision to offer single sex care and accommodation in order to meet the specific needs and vulnerabilities of this client group which may be compromised by the admission of a mixed gender group. Each bedroom has ensuite shower facilities. A bath is not available. The property has a rear garden. The property is a no smoking area although there are plans to provide a smoking shelter in the garden. There is parking for one car to the front of the property and one at the rear. Double yellow lines are on Berwick Street therefore parking is restricted. The provider has applied for permission to create more parking spaces at the front of the premises. A range of community facilities are available in the immediate local area including the Gateway centre for education and recreation, 2 GP surgeries one within walking distance, a main library, the park or ‘Quarry’, Post office, mini supermarket and three local pubs. Current fees range from £2000 to £3000 per week per service user. Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was Oakdene’s first inspection since registering as a care home. One service user is currently resident and at the time of inspection had been accommodated for 6 weeks and is settling well. The inspection was unannounced meaning that no one associated with the home received prior notification and were therefore unable to prepare. The inspection was a key inspection meaning that it was planned to assess all national minimum standards defined by the Commission for Social Care Inspection (CSCI) as being ‘key’ standards. One Inspector carried out the inspection over eight and a half hours, beginning at 9.45am and finishing at 6.15 pm. The Manager arrived at about 11am so the staff member on duty supported the inspection process until her arrival. During the inspection, the home’s Environmental Health Officer arrived to assess and advise the manager in relation to Health and Safety and Food safety compliance. This took two hours. Whilst inevitably this sidetracked the Manager and delayed the progress of the inspection to some extent, the Inspector was able to join the discussion with the benefit of avoiding duplication. Evidence to support judgements made about Oakdene’s performance has been obtained in a number of ways. The service user upon request provided CSCI with written feedback about her experiences and impressions of the service prior to the inspection on site. The Manager also provided written information to the home pre inspection. These sources of information were used in part to plan the inspection. The Inspector was able to interview the Manager, a staff member and spend time with the service user who answered questions about her experience of the service so far. The Inspector looked at this service users care in detail using evidence in written documentation and discussion with all parties. Other documentation was viewed to assess recruitment processes, protection, complaints, training and the safety of the premises. The Inspector was also able to tour the premises and join the visit undertaken by the Environmental Health Officer. It has been difficult to formulate a judgement about staff training given that staff have only been employed for six weeks and there has not been sufficient time to establish a training programme. Evidence of staff’s prior experience and qualifications was therefore sought. For this same reason the formal supervision of staff was not assessed as staff felt well supported and there were no issues of concern which unduly impacted upon the service user. This inspection found that whilst some improvements are needed, the service user was relaxed and comfortable and every effort was being made to meet her needs. Direct outcomes for the service user are considered to be good. Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home could have provided the service user with more information about the home prior to admission. Geographical distance prevented a visit before admission and at the time a Service User Guide / Brochure was not available. A Statement of Purpose was provided and there are some inaccuracies within it. The service user did not have sight of a contract either as one has not to date been developed. This does not provide the service user with sufficient information with respect to the terms and conditions of her stay. The service user has not had occasion to complain but does not know how to in the event and this information should have been provided at the point of admission. The home does not have a bath and this needs to be included in both the Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 7 Statement of Purpose and initial assessment to ensure service users are aware of this before admission. Administrative systems need to be more robust. Although it was early to assess the provision of staff training, a training matrix should be developed to support the effective provision of a staff-training programme. Staff recruitment must also be more rigorously administered to ensure compliance with the regulations for the protection of service users. There is a range of omissions in significant policies and procedures including medication, physical intervention / restraint, Infection Control, managing service users finances, Health and Safety, food safety, staff supervision, Moving and Handling, sexuality, accidents, staff grievance and disciplinary, Gifts to staff etc. These are necessary to provide staff with appropriate guidance to support them in their role. Risk assessments are in place to identify personal risk to the service user demonstrating that the Manager understands the principles of risk assessment. She must now apply herself to developing risk assessments required of her as an employer and owner of a business such as the wide range of environmental risk assessments required in respect of the premises to protect staff, service users and members of the public as none are currently in place. Although in practice, attention has been given to ensuring that the premises are in practice as safe as possible. The Manager does not have a quality assurance tool at her disposal to support the self-assessment of the homes overall performance and this when available will promote the required improvements. The service users needs to date are being met well. However there are omissions in management processes, which need to be addressed. In the Inspector’s opinion there is the potential for improvement in these identified areas. 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. Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 8 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 Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 9 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): 1, 2, 4, 5. Quality in this outcome area is adequate. Service users can be assured that their needs will be assessed and that they will only be admitted to the home if the Manager is confident that their needs can be met. The Manager must however ensure that more information about the home is provided to service users pre admission and that it is accurate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspector spoke to the Service User about her experience of the admission process to the home. A Service User Guide was not available to the first service user prior to admission. She was provided therefore with a Statement of Purpose. There are some anomalies within it, which need reviewing. The home is not registered to accept up to 4 service users as the Statement of Purpose states. The stated intention is also to admit only service users who self-administer medication. In practice this was found not to be the case. The clear intention of the home according to the Statement of Purpose and from discussion with the Manager is to admit only female service users. Verification since inspection has shown that this was not included in the homes application to Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 10 CSCI at the point of registration and the Provider should address this with CSCI’s Registration team. The home has shower ensuites available to service users rather than a bath. It would help service users if this were made explicit in the Statement of Purpose, Service User Guide and formally within the assessment process. The service user told the Inspector that she misses having a bath, ‘hates showers’ and hadn’t been aware prior to admission that a bath would not be available. Likewise following a change in Regulation the fees and fee structure must be explicit within the Service User Guide. Guidance as to how to make a complaint must also be included in detail. The service user does not know how to make a complaint and written information is not available to her. A Contract has not yet been developed to outline the terms and conditions of residency between the service user and the home. The intention is to issue this once it is agreed that the placement becomes permanent. Good information was available to the home about the service users needs and a staff member confirmed that she had been well briefed prior to the service users admission. The Manager carried out her own pre admission assessment including attention to the service users perception of need, family needs, risk and strategies required to meet need. Overall this was carried out to a good standard. There were no copies of the placing authorities assessments but comprehensive psychiatric reports were available. The service user did not have a trial visit prior to moving in due to geographical distance but this admission is a three-month trial period. Other service users being considered for future admission have enjoyed the opportunity to visit. In summary then a good assessment was carried out prior to admission but it is recommended that future assessments include bathing preferences, the detail of how medication is to be administered and service users must be provided with additional and accurate pre admission information. Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 11 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): 6, 7, 9. Quality in this outcome area is good. Care plans offer staff sufficient guidance and staff understand and respond to service user needs and rights well. Service user choice and preferences influences routines and practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Provisional care plans are in place to address significant assessed needs. These provide good guidance for staff during this 12-week assessment period. A review is planned for February. This will decide whether the placement becomes permanent. Risk was assessed well before admission and there is evidence that risk assessments have been updated since admission in response to changes and events. There is good clear evidence from written shift records, discussion with staff, discussion with the service user and from observation that routines and Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 12 activities are service user lead and that service user choices, rights and independence are well understood and promoted. Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 13 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): 12, 13, 15, 16, 17 Quality in this outcome area is very good. The home has worked creatively to ensure that the service user has been supported to enjoy a very wide range of community facilities that meet her expectation and preferences within a very short time since admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service user has a very personalised programme of activity that uses community facilities e.g. the service user has started college, enrolled at the library to use the computer facilities, been swimming and to the cinema. She is also actively involved in food shopping, had been to a concert to support a family member who was involved, had purchased Christmas presents for family and had regular contact with her family. She told the Inspector she had also been to bingo but wouldn’t be keen to return. In the written pre admission information that the service user sent to CSCI she stated a few things that she Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 14 was hoping to do. This inspection shows that she had been supported to do all of the things she had listed. Staff are aware of the service users future goals. Routines are flexible. She chooses to get up late and did so on the day of inspection having a late brunch. She confirmed that she chooses when she goes to bed and a variety of times are confirmed in records. The service user said she likes the meals. She confirmed the information given by staff that she chooses her preferred food when shopping, is involved in meal preparation and bakes. She was observed to take food out of the freezer to defrost for a meal without reference to anyone else. She also confirmed that she could help herself to drinks and snacks throughout the day. Records show a wide variety of meals and breakfasts eaten. . . Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 15 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): 18, 19, 20 Quality in this outcome area is adequate. Staff are aware of the service user’s personal care and health needs and steps are underway to maintain health and wellbeing during this early transition period. Outcomes therefore for personal care and Health are good. However, some aspects of medication management require improvement to ensure that systems are robust, accountable and safe. This has reduced the overall judgement for this group of standards to adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff are aware of their role in relation to the service user’s personal care given her level of independence. Privacy is maintained and staff were observed to knock on her bedroom door. The service users only disappointment was the absence of a bath. From discussion with staff and sight of records there is evidence that steps are being taken to meet the service users health needs. Staff are aware of further Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 16 routine screening that arrangements need to be made for and there is guidance in the care plan to remind staff of key areas. Records of health appointments would benefit from being recorded separately for ease of monitoring and review. Medication management is an area that needs some improvement. There is not a medication policy to guide practice and neither the permanent staff member nor the Manager has received training in the Safe Handling of Medication. There is no evidence on site that agency staff have received medication training although the manager believes they have and risks are increased because there is a significant amount of lone working. Systems are not in place to assure the competency of staff to administer medication and without training herself; the Manager is not best placed to undertake this. Written permission for the home to administer medication to the service user has not been obtained and she is reluctant to take it. Also the service user is not self-administering as thought and in line with the home’s purpose providing more urgency for staff training in this area. The Inspector has sought clarification about this from CSCI’S Pharmacy Inspector. The service user added that ‘Oakdene would be all right if I didn’t have to take my medication’. Guidance requesting the further involvement of staff in the administration process has been provided following an incident where a tablet was found on the floor. Once per week the service user is not receiving one dose of medication as prescribed. This is not accounted for in records and requires advice from the medical officer who prescribes it. The home must also obtain written medical authorisation for the use of homely remedies to minimise the risk of contra indication with prescribed medications. Other medication is being administered regularly and records account for this. The lockable medication cupboard has not yet been secured but the manager is aware of the need to do this and all medication prescribed was available and tallied with records. Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 17 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): 22, 23. Quality in this outcome area is adequate. There have been no complaints and the service user feels safe. However systems need to be developed further to ensure that service users know how to raise concerns and complaints. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service user has not wanted to make a complaint but said she is not aware of how to make a complaint. Further enquiries show that policy / procedures have not been provided to her and are not available without asking. No complaints have been received by the home but positively a log is available to ensure complaints are recorded and are acted upon in the event. There have been no accidents, incidents or restraints in the short time since the home became operational on 1st December 2006. The service user is settling well and the Manager knows signs of relapse. The Manager as a social worker previously, said she has experience of managing adult protection situations and although the manager could not locate the homes own adult protection policy, multi agency local guidelines are available on the premises. The Manager said she favours a no restraint policy and this needs formalising so guidance is clear. Staff will need to be provided with adult protection training with certificated evidence. Currently the home has no involvement in the management or handling of the service users money. The Manager is aware that this situation may need to Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 18 change as more service users are admitted to the home whose needs may differ. Policies and procedures will need to be made available. Recruitment practice is partly protecting service users but could be more robust to offer fuller protection. This is discussed under ‘Staffing’ later in this report. The service user said she feels safe with there being ‘no abuse or nothing’. She said that staff are kind. Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 19 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): 24, 30 Quality in this outcome area is good. Premise are refurbished and renovated to a high specification and provide homely, clean and modern accommodation that meets the current service user’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the environment found it to be newly renovated to a high standard, modern, comfortable clean and fresh with no evident safety risks. Radiators are all covered, there are no obstructions, no hazardous chemical products are on display and door locks are overridable. A quiet room is available for visitors. Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 20 The service user said she likes her bedroom and has all she needs with the only concern being a lack of a bath as showers are provided throughout the property. Showers meet her need but not her preference. Soiled laundry has to be carried through the kitchen but action is taken to minimise risks to food of cross contamination. Laundry tasks are domestic in style and risk. But the home would benefit from an infection control policy and procedure to guide staff in the event of the need to manage bodily fluids. The Environmental Health Officer identified this issue up at inspection and advice was given. The service user is involved in domestic tasks within the premises. Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 21 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): 31, 32, 33, 34, 35 Quality in this outcome area is adequate. Staff present as interested, motivated and committed. Some training courses have been booked for staff but a training plan is needed to help manage the training programme as the home grows. The Manager feels that service users are protected as to date she has employed only a trusted previous colleague and agency staff where the agency carries out suitability checks. However from the evidence available recruitment systems are currently poor and do not fully protect service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Currently the home employs one member of permanent staff and is using agency staff to supplement the staffing contingent. Staff spoken to present as interested and motivated and work in creative ways to meet the service user’s needs. The Manager and service user are satisfied with the quality of staff supplied by the agency. Other staff have been recruited and are waiting checks to start. The Manager also intends to employ administrative help. When the Manager is on duty there are two ‘staff’ available to support one service user although during evenings and weekends this drops to 1:1. The Manager said that this has been assessed as safe, that the purchasers of Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 22 service are satisfied with this and there have been no incidents or concerns to indicate that this is not acceptable to meet the service users assessed need. The Manager is aware of occasions when 2 staff are required to provide staff and this has been possible. The rota management must improve, as this is a legally required document. It must be written in ink, not pencil must include the surnames and designations of staff including the ‘sleep in’ function, must include the Manager and delineate between her management and care roles. One permanent staff member has been recruited. It is positive that a Criminal Record Bureau check including a POVA check was carried out prior to the staff member starting. However no other documentation required by either regulation and / or National Minimum Standard had been obtained e.g. (references, identification, photo, a statement by the person re mental and physical health, no evidence of qualifications or training, job description, no contract of employment, no application form and therefore no employment history, no interview evidence). The Manager feels that the recruitment risks were minimal because she knows the staff member appointed. In addition there is no evidence of any suitability checks and training for agency staff working within the home. There is evidence that applicants unknown to the Manager who are currently being recruited are being recruited more thoroughly. Job descriptions and contracts ensure that roles and responsibilities are clear and unambiguous. These have not been provided and have lead to some confusion over a staff member’s designation and this needs to be resolved. Five weeks after the appointment of staff is too early to assess the programme of training provided. However, it was also not possible to assess how appropriately trained the staff member was at the point of appointment as there was no evidence of any prior training although discussion with her evidences previous appropriate experience and knowledge. The Manager is beginning to book some training courses and was advised to develop individual and group training matrices to support the planning of the home’s training programme. Certification must be held on the premises to evidence the outcomes of courses booked. The Inspector explained the need for the Manager to ensure that appropriate induction and NVQ training is provided for unqualified social care staff to the national standard. The provision of formal supervision was not assessed at this early stage five weeks after appointment. The Manager however is aware of the need to provide all staff with a minimum of 6 supervisions annually. A staff member confirmed that she feels exceptionally well supported. A first staff meeting has been held between the providers / Manager and the permanent staff member. Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 23 Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 24 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): 37, 39, 41, 42 Quality in this outcome area is adequate in line with the need to take a proportionate approach to this new service where outcomes for the service user are good, and there appears to be no obvious immediate hazards. However failure to comply with the significant omissions identified would result in a ‘poor’ judgement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager is registered with the Commission for Social Care Inspection and is an experienced Social Worker with experience of working with people with mental health needs. She has started her NVQ 4 in Management. Inspection demonstrated that she has an awareness of what her learning needs are. She is clear about what she wants the service to be and who will benefit from it Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 25 most. At this early stage the Manager has demonstrated some good outcomes for a service user who is settling well. The Manager is aware that her learning needs are in relation to management and employment issues, as this does not form the basis of her previous experience. The outcomes from this inspection concur with this. However she demonstrated a willingness to receive feedback in order to help the home to develop and to meet the national standards. In discussion the Manager identified the need to develop a strategy to ensure that she receives appropriate supervision and said that she would explore this further. She was also aware of the need to ensure that Regulation 26 visits are carried out by the Responsible individual and said that this would be arranged. A staff member spoke highly of the Manager saying she has confidence in her. It is judged that there is the potential for improvement. An Environmental Health officer undertook the first health and safety including food safety visit over the course of two hours on the day of this inspection. This highlighted a wide range of learning opportunities for the Manager and actions needed especially in relation to risk assessments. The Environmental Health Officer will write to the home confirming her findings and advice and will copy CSCI in to the letter. The Manager was aware that there would be omissions in certain areas and looked on the inspection process as a bench marking exercise. The Manager does not have a quality assurance tool available to her. This is a regulatory requirement and will when in place enable her to self assess and respond to the performance of the home. Current identified omissions in health and safety practice, which must be prioritised for remedial action, are: • • • • • • • • • No Health and Safety policy No environmental risk assessments No fire risk assessment No fire drills No fire training –although this is booked for March. Fire system test records were not available, as they had been mislaid. No water outlet temperature monitoring – although valves are fitted to help to safe guard temperature control. No COSHH assessments No hot food temperature monitoring There is a range of omissions in significant policies and procedures including medication, physical intervention / restraint, Infection Control, managing service users finances, Health and Safety, food safety, staff supervision, moving and handling, sexuality, accidents, staff grievance and disciplinary, gifts to staff etc. These are necessary to provide staff with appropriate guidance to support them in their role. Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 2 32 2 33 3 34 1 35 2 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 2 X 1 1 X 2 X Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4(1)(C) 5 Requirement The Registered Manager must ensure that: The home’s Statement of Purpose and Service user guide is reviewed to accurately reflect the number of service users the home is registered to accommodate. The homes Statement of Purpose and Service user Guide must include in sufficient detail the arrangements for dealing with complaints / a summary of the procedure. The homes Service User Guide must include all information relating to fees, charging structures, terms and conditions and must include a standard form of contract as per regulations 5(1a) to 5 (1e) When updated, the revised documents must be issued to all service users. 2 YA20 13(2) The Registered Manager must DS0000067573.V316087.R01.S.doc Timescale for action 31/03/07 28/02/07 Page 28 Oakdene Care Providers Version 5.2 ensure that the home has a medication policy which provides guidance based on professionally recognised good practice for all aspects of the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The Registered Manager must as a priority ensure that all staff including the Manager receives appropriate medication training. The Registered Manager must develop a system to ensure the ongoing competency of all staff to administer medication, including agency staff. The Registered Manager must ensure that where medication is not being administered as prescribed this must be reviewed with the prescribing medical practitioner without delay. The Registered Manager must ensure that any medication not administered as prescribed is accounted for in medication administration records. The Registered Manager must ensure that written medical authorisation is obtained for the administration of homely remedies for individual service users. The medication storage cupboard must be appropriately secured. The Registered Manager must supply a written copy of the complaints procedure to current DS0000067573.V316087.R01.S.doc 3 YA22 22 31/01/07 Oakdene Care Providers Version 5.2 Page 29 and future service users. 4 YA23 13(6) The Registered Manager must make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. E.g. By the provision of evidenced staff training in adult protection. By developing policies regarding the management of service users monies, gifts offered to staff etc By developing a physical intervention policy that accords with current guidance and good practice. 5 YA30 13(3) The registered person must provide an infection control policy to appropriately guide staff how to prevent infection, toxic conditions and the spread of infection at the care home. 19 The Registered Person shall not employ a person to work at the care home unless full and satisfactory information and documents in respect of that person as per Regulation 19 and Schedule 2 have been obtained. 18(1)(C)(i) The Registered Manager must ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform including structured induction training. 24 The registered person must establish and maintain a system for evaluating the quality of the DS0000067573.V316087.R01.S.doc 31/03/07 30/04/07 6 YA34 31/01/07 7 YA35 31/03/07 8 YA39 31/07/07 Oakdene Care Providers Version 5.2 Page 30 services provided at the care home. This system must provide for consultation with service users and their representatives. 9 YA39 24 The Registered Person shall produce an improvement plan setting out the methods by which and the timetable to which, the registered person intends to make the required improvements. The Registered Manager must ensure that the roster is a full and accurate record of persons working at the care home and that it demonstrates that at all times staff are provided in appropriate numbers. Following consultation with the Environmental Health Authority at their visit of 9.1.07 the registered persons must ensure that all required improvements are complied with in accordance with compliance dates set by that Department. 31/01/07 10 YA41 17(2) Sch 4(7) 18 31/01/07 11 YA42 23(5) 13(4) 28/02/07 12 YA42 23 4 (4A) The Registered Person must ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. The Registered persons must 31/01/07 ensure compliance with all Fire Safety regulations. As a priority the Registered Manager must carry out a Fire Risk assessment and implement any control measures to minimise any risks identified by 31.1.07. Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 31 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 YA1 2 YA1 3 YA2 Refer to Standard Good Practice Recommendations The Registered Manager should consider writing to CSCI Central Registration team to amend the registration of the home to ‘female’ only to comply with the purpose of the home as stated in the homes Statement of Purpose. The Registered Manager should consider including in the Statement of Purpose and the Service User Guide arrangements for bathing including specific reference to the absence of bath facilities. The Registered Manager should consider developing the current pre admission assessment pro forma to ensure that medication administration needs are assessed in more detail and that bathing preferences and or needs are included. The Registered Manager should ensure that clearly defined job descriptions and contracts of employment are developed for all staff positions and are provided to all staff, with a signed copy held on file. The Registered Manager should ensure that each staff member has an individual training and development assessment and profile. The Registered Manager should ensure that a training needs assessment is carried out for the staff team as a whole to inform future planning. This should be linked to the homes aims and service user needs. The Registered Manager should ensure that all policies and procedures as per Appendix 2 of the National Minimum Standards are provided to guide staff within the home. 4 YA31 5 YA35 6 YA41 Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Oakdene Care Providers DS0000067573.V316087.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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