Inspection on 05/09/07 for Oaklands Road, 82

This inspection was carried out on 5th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oaklands Road, 82 10/01/07

Oaklands Road, 82 04/01/06

Oaklands Road, 82 09/08/05

Oaklands Road, 82 01/02/05

Oaklands Road, 82 09/09/04

Oaklands Road, 82 24/02/04

Oaklands Road, 82 15/07/03

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 Oaklands Road, 82 Hanwell London W7 2DU Lead Inspector Sarah Middleton Key Unannounced Inspection 5th September 2007 09:55 Oaklands Road, 82 DS0000027737.V347862.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 Oaklands Road, 82 DS0000027737.V347862.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. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oaklands Road, 82 Address Hanwell London W7 2DU 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) 0208 840 5996 hm82oaklands@ealing.org.uk Ealing Consortium Limited Allyson Clancy Care Home 3 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0), Mental disorder, excluding of places learning disability or dementia (0), Mental Disorder, excluding learning disability or dementia - over 65 years of age (0) Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2007 Brief Description of the Service: 82 Oaklands Road is a registered home for three people with learning disabilities and/or mental health needs. The home is registered to take residents over sixty-five years old if their needs can be met. There is currently one resident over sixty-five years old. The home is managed by Ealing Consortium and owned by Catalyst, formerly known as Ealing Family Housing Association. It is located in a terraced house in a quiet residential road. It is close to local amenities, including shops in Boston Manor Road. There are transport links on the Uxbridge Road in Hanwell, which lead to larger towns such as Ealing Broadway. There are leisure facilities available in the local area. There are three single bedrooms, one on the ground floor and two on the first floor. There is one lounge, a dining room with adjacent kitchen and a small laundry area on the ground floor. The first floor has a bathroom/toilet and separate toilet with an office/sleeping in room. There is a garden to the rear, where there is decking leading off from the kitchen and a patio area with gravel, plants and shrubs. There is a small garden to the front and parking is on the street. Fees range from: £22,468-£24,420 per resident, per annum, with some financial contributions made towards this fee by the resident. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The previous term service user will be replaced in this inspection report and the term resident will be used and refers to the people living in the home. This was an unannounced inspection carried out as part of the regulatory process. The inspection visit was from 9.55am-5.25pm. The Registered Manager is currently working at another registered care home run by the same Registered Provider covering maternity leave. She is expected to return to the home in approximately eighteen months time. Therefore there is currently an interim Manager Designate who is in the process of applying to become the interim Registered Manager of the home. The Manager Designate and support workers assisted with the inspection process. The Inspector toured the home, viewed residents files and maintenance records. The Inspector met all three residents and observed staff with the residents. One relative completed a postal survey and spoke positively about the staff team. The Registered Provider is in the process of joining with another Registered Provider. Therefore the Registered Provider will be known as another name in the near future. It is not yet known whether this change will have any significant affect on staff and/or residents. All of the key National Minimum Standards were assessed and four of the six previous requirements were met and two new requirements made. What the service does well: The home provides residents with choices and opportunities to make decisions about their lives. Staff are aware of the individual needs of the residents. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Oaklands Road, 82 DS0000027737.V347862.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 Oaklands Road, 82 DS0000027737.V347862.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents would be assessed prior to moving into the home. EVIDENCE: The home has not had any admissions for several years. The Manager Designate confirmed that a prospective resident would have the opportunity to visit the home, stay overnight and meet with staff and the other residents. The Inspector viewed a blank pre-admission assessment that would be used. This document covers a wide range of areas relating to a resident’s needs, such as, their physical, social and mental health needs, the support the resident will need and their cultural needs. The prospective resident would be expected to be involved in the assessment process, along with relatives and any other persons involved in the prospective resident’s life. Oaklands Road, 82 DS0000027737.V347862.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): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are comprehensive and outline residents’ individual needs. Residents are supported and encouraged to make daily decisions about their lives. Not all risk assessments were comprehensive and some did not outline potential risks. Residents need to be safeguarded by the information recorded about their needs. EVIDENCE: The Inspector viewed two residents’ files, which included care plans, reviews and daily records. The care plans had been reviewed and reviews included looking at the resident’s health, personal and social needs. Reviews also take into account any aims set at the previous review and comments on whether these have been met. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 10 Changes to a resident’s needs over the past six months are also discussed. Residents and relatives are invited to reviews and the Inspector was informed that relatives usually attend. Guidelines were viewed that provide staff with clear details as to how to support the resident both in the home and/or in the community. Personal care assessments were seen and these aim to offer guidance for staff so that they are fully aware of exactly when a resident is independent and areas where he/she might need assistance and prompting. The Inspector noted that for one resident her personal care assessments had not been reviewed for over a year and this was brought to the attention of the Manager Designate. Some residents’ files still had documents such as, risk assessments and personal care assessments that although had been reviewed the original had been written, in some cases, over six years earlier. This had been identified at the last inspection and a recommendation was made again for documents to be written again, as needs and risks can change and staff need to carefully consider the information that is written and assess whether this is relevant to the resident. Samples of daily records were read; in particular the Inspector viewed the daily records regarding an incident that occurred whilst a resident had been on holiday with staff. The daily records had documented the incident and the action taken and who was notified. The daily record for another resident relating to similar concerns earlier in the year were not seen at the inspection as the daily books were not in the home. Subsequent to the inspection, the Inspector saw copies of these daily records that recorded the action staff took. (See Standard 23 for further details). Monthly summaries are written and provide an overview of how the resident has been over the month and whether there have been any changes in needs. One resident has an advocate and she takes the resident out in the community on a regular basis. The other two residents are on a waiting list to also have an advocate allocated to them. Residents are not able to manage their own finances but are encouraged to make everyday decisions with assistance from staff. Staff were seen to provide residents with choices during the inspection and staff spoke of encouraging the residents to make decisions about their individual lives. Residents can refuse to take part in tasks and/or activities. The staff team respects each resident’s decision. Risk assessments were now in place for those residents who can refuse medical treatment. Issues of consent would need to be assessed and using the Mental Capacity Act 2005 would be necessary where there were concerns that residents did not understand the implications of refusing health treatment. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 11 The Manager Designate had devised a holiday file that included information such as, risk assessments, details of the local hospitals and the local Police. This will aim to support staff if an accident or untoward event occurs on holiday and will support staff to act appropriately and safely for all those concerned. In general risk assessments outlined the identified risks. Consideration is given to the risk towards the resident and others and the assessments record the action to take to minimise the risk. The Inspector noted that with regards to the residents who have had unexplained bruising, no risk assessments had been completed. This was brought to the attention of the support worker for one of the resident’s and the Manager Designate. A partial re-stated requirement was made for staff to consider and complete risk assessments on all potential risks. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to engage in activities both in the home and in the community. Residents are supported to maintain social relationships. The residents’ rights are respected in their daily lives. Residents are provided with a healthy and varied diet. EVIDENCE: The three residents take part in various activities. Two residents attend a local day centre two days a week. The home is in the process of liaising with the day centre, as due to a change in criteria, the two residents from the home will no longer be eligible to access this resource. For one resident in particular, due to her specific needs, this change in her routine will be stressful and confusing. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 13 Staffing levels will also need to be looked at if all three residents will be at home every day. At least once a week residents have one to one support and time with a member of staff, although this might change if the day centre provision ends. Other places are accessed such as the church, cafes and pubs. Recently the home has identified a musical club held on a Saturday evening. The residents appear to enjoy this new social event. The home does not have its own car, although this can be arranged. For the most part residents either use public transport or use taxis. The residents are invited on occasion to social events held by the next-door neighbour. Residents are encouraged to see their relatives and are supported to visit them and to speak to them on the telephone. Staff can take residents to visit relatives, this is particularly important where a relative is elderly or lives far away. The different activities available in the home and community also enable the residents’ to meet and socialise with other people. The daily routines of the home promote residents to make choices and have the opportunity to decide on what they want to do each day. Although there is a structured plan for each day this can be adapted depending on what the resident wants to do. Staff informed the Inspector that staff read resident’s personal mail to them, as all three residents are unable to read. Staff were seen to interact with the residents throughout the inspection. Residents can choose when to be with others in the home or when they wish to spend time alone. During the inspection the Inspector sat in the garden with two residents whilst the other resident sat in the lounge, as this is the room she likes to spend time in. The Inspector sat with one resident during lunchtime. Meals are taken in the dining areas, which is part of the kitchen. Residents are encouraged to assist with some meal preparation but generally the residents watch staff prepare meals. Staff told the Inspector that residents might lay or clear the table but rarely take part in the actual cooking of food. The resident at lunchtime had choices offered to her and was able to choose the meal she wanted. When asked the resident was able to say what her favourite meal was. Residents are encouraged to choose the weekly meals they like, and staff are now introducing cultural meals to offer even more variety to the residents diet. Two residents have high cholesterol levels and staff monitor and record the foods the residents are eating. Residents eat out once or twice a week. Fresh produced is used and processed foods are avoided. Foods that had been opened had been covered and dated. Fridge and freezer temperatures are taken daily and were within an appropriate range. The worktop near to the sink had holes in it, (See Standard 24 for further information). Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in their preferred way. The health needs of the residents are identified and were being met. The robust medication systems that are in place safeguard the residents. EVIDENCE: All three residents need a certain amount of support when managing their personal care. Staff are aware of the areas each resident needs assistance with and guidelines and personal care assessments are in place to inform staff. Personal care is always provided in private. Times for getting up and going to bed are flexible. One resident likes to wear accessories and chooses what to wear each day. Residents’ buy their own clothes, with support from staff. The Manager Designate has been liaising with the local Speech and Language therapist looking at alternative ways to communicate with one of the residents. She is hopeful that staff will consider the new ways to communicate with the resident in order to meet the resident’s specific needs. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 15 This resident showed the Inspector the calendar she has in her bedroom that shows when particular events are occurring such as going to church and Christmas. The resident seems to respond to visual pictures and this will develop as information and advice is sought from the Speech and Language therapist. Residents’ health needs are clearly recorded on their care plans and reassessed at reviews or when there has been a significant change in need. All residents have access to health professionals, such GP and dentist. Issues of consent are considered, in particular when there could be future possible health concerns. Staff document when residents have attended a health appointment. The medical appointments form outlines any advice or treatment discussed and planned. The Manager Designate is aware that the OK health checks usually carried out with the local community learning disability nurse are overdue. This needs to be followed up to ensure any changes are identified and recorded along with any necessary action to be taken. The Inspector viewed a sample of medication. Medication is stored in a safe and secure cabinet. The residents are not able to self-administer their own medication. All medication is checked and counted on a regular basis and recorded to minimise medication errors occurring. Staff receive medication training when they first start working in the home but had not received refresher training or any assessment of their competency to administer medication. This was discussed with the Manager Designate, as Pharmacists can provide training or provide medication workbooks that staff would work through to assess their knowledge and awareness of handling medication. The Manager Designate agreed to look into this. The loose medication in bottles or boxes was counted and correct at the time of the inspection. The home has information on the medication in the home along with details of the side effects. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents would be supported to make a complaint. Systems are in place to protect residents from abuse. EVIDENCE: The home had not received any complaints. The complaints procedure is in the pictorial Service User Guide and is freely available. One of the residents would be able to verbalise her concerns and complaint. The other two residents would find it difficult to communicate their particular concerns. Body language, gestures and sounds will inform staff if a resident is unhappy. One resident, as mentioned earlier, has an advocate and having this objective form of support this could benefit the other two residents. The home has had two adult abuse investigations since the last inspection, both relating to two different residents. The first incident was not reported quickly and did not fully follow the adult abuse procedures. The Registered Provider investigated this incident. Alongside this, an investigation also took place with regards to the action staff did not take to report this incident within a reasonable timescale. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 17 The second incident that occurred a few months after the first incident was also investigated. There was no clear conclusion as to how the two incidents had occurred and no indication that abuse had occurred. One staff member spoke to the Inspector, as they had been involved in reporting the two incidents. She was concerned that her practice would be scrutinised due to her reporting of the incidents. After the second incident the staff team met and spent time looking at what could have been done differently and what staff need to think about when supporting a resident and reporting any concerns. The Inspector was satisfied that appropriate action was taken to investigate how the incidents could have occurred. All staff need to receive refresher training on adult abuse to ensure they all know what action to take as soon as they have concerns, (See Standard 35). The Inspector counted two residents’ personal monies and found these to be correct at the time of the inspection. All financial transactions are recorded and receipts are obtained. The residents’ money is checked and counted every day. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The kitchen worktops need to be hygienic and welcoming for the residents who live in the home. Overall the home was clean and free from odours. EVIDENCE: The Inspector toured the home and saw that the bathroom had begun to have work carried out. The bath panel had been replaced and the old rusty shelving unit had been taken down. Residents had chosen the paint colour for the wall. Progress was slow, as the residents still need to use the bathroom on a daily basis. The Inspector was satisfied that the work would be finished as soon as possible. The garden is well maintained and residents were seen to access it at the time of the inspection. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 19 The Inspector noted that the kitchen worktop near to the sink had several holes on it. This is unhygienic and needs to be made good or new worktops need to be fitted that will be durable. This was discussed with the Manager Designate and a requirement was made for this to be addressed. The laundry facilities are located in a small cupboard in the dining area. Residents are supported to carry out their own laundry tasks. The staff team keep the home clean and at the time of the inspection the home was clean and pleasant for the residents. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and effective staff team support the residents’. Robust recruitment checks safeguard the residents. The training programme needs to meet the needs of the staff and consequently the residents. EVIDENCE: The staff team have worked together for sometime and have an understanding of the needs of the residents. During the inspection staff were seen to listen and talk with the residents in a sensitive manner. All of the staff team bar one have obtained an NVQ. The newest member of staff had completed the Learning Disability Award Framework. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 21 External agency members of staff are used as there is currently one member of staff on maternity leave and another member of staff is due to go on a one year career break at the end of the month. Where possible the existing permanent members of staff, including the Manager Designate cover the vacant hours, or regular bank staff work in the home. The home tries to ensure that there is a consistent staff team supporting the residents in order to avoid causing stress and confusion. The Manager Designate is in the process of recruiting two people who will work for one year to cover the two vacant posts. The staff team had been through difficult times and this had been noted at the previous inspection. Those staff spoken with at this inspection commented more positively on how the staff team were working more effectively and that communication had improved. The Manager Designate still feels there is room for improvement and with the two new members of staff joining the team she will look to support the staff team to work even more effectively together. A team review is planned in the near future and this will aim to focus staff to work towards the same objectives. Staff meetings take place on a regular basis and enable information to be shared amongst the staff team. The Manager Designate has been the most recent person to join the staff team. The home holds general information about staff on a pro-forma document. This contains confirmation that two references had been obtained; confirmation that health checks had been carried out, Criminal Record Bureau Check disclosure numbers and gaps in employment explained. The main staff employment files are held at the local head office. The Inspector viewed a proforma regarding a support worker, however the Manager Designate details were not available at the time of the inspection, but were subsequently seen following on from the inspection. The Inspector viewed the induction process that external agency members of staff work through. The Manager Designate intends to use this document and adapt it for permanent new members of staff. New staff also receive an induction from the main head office and the mandatory training is organised soon after the new member joins the staff team. Staff have an individual training plan and for the most part training was up to date. Those staff asked said they were happy with the training they had received. Discussions took place with the Manager Designate regarding moving and handling as a document was seen at the inspection that stated moving and handling must be offered as a refresher course once a year with the main two-day training to then be offered every three years. The Manager Designate will check to ensure this document is still valid. Due to the recent two adult abuse investigations the staff at the home need to have refresher training on this subject. Therefore in light of the above a re-stated requirement was made for the training programme to meet the staff teams’ needs. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 22 The Manager Designate is aware of the Mental Capacity Act 2005 and staff have been provided with an overview of this legislation. It is not clear at this stage how this legislation will be implemented into the daily work practice in the home. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ benefit from a well managed home. Residents’ views need to be sought regarding the home and an overall report needs to be developed in order to evidence the work the home has undertaken to improve the care provided to residents. The residents’ health and safety is promoted through robust maintenance checks being in place. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 24 EVIDENCE: As mentioned in the summary of this inspection report, the Registered Manager had been on maternity leave and is now working for eighteen months at another registered care home, owned by the same Registered Provider. The Manager Designate joined the staff team approximately seven months ago and is in the process of applying to become the interim Registered Manager. The Manager Designate has worked in various care services over many years and is on the waiting list to study for the NVQ level 4. Staff spoke positively about the Manager Designate stating she was approachable to talk to. The CSCI receive monthly Regulation 26 reports. These look at various areas relating to the home, such as environment, staffing and seek to obtain residents’ views. The Manager Designate informed the Inspector that surveys for residents to answer questions about the home had not been carried out this year. Although on a daily basis the home consults with the residents, it is important to obtain the residents particular views about the home they live in. The Manager Designate also completes a report that that looks at various areas such as staffing and health and safety. The Inspector discussed the need to bring together all of the different aspects of reviewing the care provided in the home and to complete a short report or summary outlining where the home has made improvements and areas still to be addressed. This report should then be made available for the residents and for inspection. A requirement was made for this report to be developed. The Inspector viewed a sample of maintenance records. The home takes the temperature of the bath on a daily basis and the water in all areas of the home on a weekly basis. The Gas Safety Record and Portable Appliance test were up to date. The testing for Legionella was recently out of date and subsequent to the inspection the Manager Designate has been liaising with the housing trust to arrange for this to be carried out as soon as possible. The home had an external fire organisation carry out a fire risk assessment and a member of staff from each registered care home had been trained to carry out a more personal fire risk assessment on each home. A fire capability form regarding each resident had been completed the previous year and the Inspector pointed this out to the Manager Designate who will review and update this document. Fire drills had been held on a regular basis and at different times of the day and evening. The Manager Designate needs to monitor the staff who attend the fire drills so all members of staff attend them on a regular basis, as one member of staff had not attended a fire drill for over a year. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 25 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 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 3 x Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 26 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 YA9 Regulation 13(4)(c) Requirement To safeguard residents and others risk assessments must be completed on any potential risk, e.g. where there is a risk of bruising. (Partially re-stated, previous timescale 06/02/07 not met). Timescale for action 21/09/07 2. YA24 23(2)(b) 3. YA35 To ensure residents live in a 24/12/07 welcoming home that is free from bacteria, the kitchen worktop that is marked needs to be made good or replaced. 18(1)(a)(c)(i) Training, including refresher 31/12/07 training, must be available for staff, e.g. moving and handling refresher training & adult abuse. (Previous timescale 28/04/07 not met). Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 27 4. YA39 24(2) For the benefit of the residents the home must be able to evidence how it has made improvements and outline the future aims and objectives of the home. This evidence needs to be made available in the form of a short report/summary. 07/01/08 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 YA6 Good Practice Recommendations It is strongly recommended that documents relating to service users, such as personal care assessments and risk assessments be re-written and reviewed on a regular basis. Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Oaklands Road, 82 DS0000027737.V347862.R01.S.doc Version 5.2 Page 29 - 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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