Inspection on 15/02/06 for Oakley Square Project

This inspection was carried out on 15th February 2006.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oakley Square Project 06/02/07

Oakley Square Project 09/09/05

Oakley Square Project 22/02/05

Oakley Square Project 28/10/04

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

CARE HOME ADULTS 18-65 Oakley Square Project 69 Oakley Square London NW1 1NJ Lead Inspector Ms Pippa Treadwell-Smith Unannounced Inspection 15 February 2006 13:00 th Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 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 Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 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. Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Oakley Square Project Address 69 Oakley Square London NW1 1NJ 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) 020 7388 1112 0207 388 1114 Equinox Ms Gerdy Grafendorf Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th September 2005 Brief Description of the Service: 69 Oakley Square is a care home providing accommodation and care for up to eight women, who have a history of mental health needs and may have had admission to Special Hospitals or medium secure units. Generally service users may remain at the project for three to five years during which time they are supported to achieve as full and active life as possible. The property is subject to management agreement with St Pancras and Humanist Housing Association who are responsible for the major repairs and most of the maintenance. The registered care service is managed by Equinox, which is a voluntary organisation. The house itself is a five storey Victorian building in a residential street in Camden, situated opposite a small park. There is a small, enclosed garden to the rear. The property is situated between Camden Town Underground and Euston Station, which are within a ten-minute walk from the home. The property itself is over five floors. However, living accommodation for service users is over four floors. The house has eight single bedrooms, two lounges, one of which is non-smoking a kitchen with a dining area and activity rooms, two bathrooms and a shower room a single toilet plus two offices and a sleep in/meeting room for staff. Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the inspection year 2005/2006, which took place over one afternoon and lasted about three hours. The manager and permanent staff team were not available to assist with the inspection as they were attending an off-site meeting. At the time of the inspection, bank workers who were familiar with the running of the home and the needs of the service users were staffing the home. The inspector was able to have brief discussions with the two service users. A variety of records were looked at including care plans and maintenance records. What the service does well: What has improved since the last inspection? What they could do better: The registered manager has been deployed to another home on a temporary basis. However the Commission for Social Care Inspection has not been notified. Although the home has been left in the care of a competent person, the period of absence has gone beyond three months. Various records were not available at the time of the inspection and the inspector will be contacting the organisation separately to look at ways that this can be resolved. The registered persons must ensure that there is a review of the quality of care provided by the home. An annual service user survey should be conducted and produced in the format of a report, and a copy made available to the service user. Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 6 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. Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 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 Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection EVIDENCE: Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection EVIDENCE: Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 17 Each service user is supported on an individual basis to follow a health eating plan. EVIDENCE: Four care records were examined. Service users are expected to take responsibility for their own shopping and cooking. They have access to a fully equipped kitchen and proper storage facilities. Each service user has a weekly menu sheet, which includes a shopping list. The records for the week of the inspection show that service users are at varying stages of ability and development. The records show the personal choices that service users are making; and that guidance on healthy eating options is provided by support staff. Some of the weekly plans are more up to date than other and contain more detail. These records reflect the content of the care plan, which include following a healthy eating plan and meeting dietary needs of service users from an ethnic background. Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18 Service users living in Oakley Square are treated as individuals and receive a support service, which mirrors their needs. EVIDENCE: The home does not provide personal care. All service users are allocated key workers. It is clear from the care records and discussion with service users that service user views are clearly expressed in the care plans as well as the key working meetings. All service users are invited to sign their care plans and the minutes of the key working sessions. Service user and key worker agreement determine the level of personal care provided, which again is reflected in the individual plan of care. Service users confirmed that they are included in all aspects of their care. They complimented the staff for thie support, patience and understanding. Staff interaction with service users was observed during the inspection. Staff were seen to offer flexible and sensitive support. Service users participate in house meetings and confirm that they are able to express their views and opinions. It is evident that suggestions, where applicable are followed through by staff. The care plans show that support is given by staff to maintain important relationships in a positive way. Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 12 The ethos of the home is to balance rights, risks and responsibilities. To enable this, there is a clear risk management system in place. Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection EVIDENCE: Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 24 There is a repair system in place to ensure that service users continue to live in a comfortable and well-presented environment. EVIDENCE: A maintenance log is available for inspection. It provides a system where the completion of repairs are monitored and brought forward if they have not been addressed. The areas identified as requiring attention have been attended to. The rotten woodwork in the bathroom has been replaced. The tumble dryer is now fixed and plumbed in correctly and a request for the vanity units to be replaced has been submitted. One service user confirmed that the vanity units had received attention because she had been aware of the work. Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32 & 34 It was not possible to get a clear picture of the staff training and recruitment and selection process as the permanent management team was not available. EVIDENCE: Previous inspections have highlighted that the organisation offers a range of appropriate training to enable staff to meet the needs of the service users. It was not possible to identify whether 50 of the staff team have achieved an NVQ qualification. The management will be asked to supply a comprehensive list of training and qualifications. The service users are all female and there is an all women staff team. Earlier visits to the home have shown that the recruitment and selection process is robust and thorough. The lead inspector will be writing to the organisation to discuss the manner in which staff records should be maintained and available in the home for inspection. Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 37 & 39 There is no current review of quality of care for service users. EVIDENCE: The lead inspector was made aware that the registered manager is managing another home on a temporary basis. The absence of more than 28 days has not been notified to the Commission for Social Care Inspection. The absence has extended beyond a period of 3 months. A competent person has been left in charge to manage the home. There has been no annual service user survey completed. The home will need a format for an annual service user survey. This will enable them to measure their success in achieving the aims and objectives of the home. However service users constantly give feedback about how they fell about the service they receive through key working sessions and house meetings. Regulation 26 reports are available in the home except for December 2005. The reports will require more information that is previously included. It is evident that the person responsible for completing the visits and reports is Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 17 visiting at different times of the day and is coming on a monthly basis. However there are no detailed comments included from discussions with staff and service users. Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 18 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 X X X 2 X 2 X X X X Oakley Square Project DS0000010344.V250188.R01.S.doc Version 5.1 Page 19 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 YA32 Regulation 18(1)(a) Requirement Timescale for action 31/03/06 2. YA34 19(5) 3. YA37 38(2), (4) & (5) 4. YA39 24 (1)(2) & (3) The registered person is required to submit an overall training plan. The plan should contain an identification of the training needs of each staff member and training which, has been completed or is proposed to meet those needs. The registered person must 31/03/06 ensure that there is full and satisfactory information available for each member; to show that the recruitment and selection process is robust and thorough. The current lead inspector will be writing to the organisation. Where the registered manager is 13/03/06 to be absent from the home for more than 28 days, the Commission for Social Care Inspection must be informed. The registered person must 01/06/06 ensure that there is a review of the quality of care provided at the care home. An annual service user survey should be conducted and produced in the format of a report. A copy should be made available to the service users. DS0000010344.V250188.R01.S.doc Version 5.1 Oakley Square Project Page 20 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 YA35 Good Practice Recommendations The inspector recommends that refresher training with regard to Adult Protection should be available to all staff at least once each year. 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