Inspection on 09/09/05 for Oakley Square Project

This inspection was carried out on 9th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Oakley Square Project 06/02/07

Oakley Square Project 15/02/06

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 Jill Marriott Announced 9 September 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Oakley Square Project Address 69 Oakley Square, London, NW1 1NJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7388 1112 020 7388 1114 Equinox Ms Gerdy Grafendorf Care Home 8 Category(ies) of MD Mental Disorder registration, with number of places Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No conditions Date of last inspection 22 February 2005 Brief Description of the Service: 69 Oakley Squareis a care home providing accomodation 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 reparairs 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 accomodation 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 G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection for 2005/6. The inspection was unannounced and took place over 4.5 hours during a week day. The inspector took time speaking to service users, members of staff and the homes manager. The remainder of the time was spent examining records, touring the building and observing interaction between staff and service users. Comment cards were sent out with the pre inspection documents none were returned to the commission. 26 standards were assessed during this visit. 25 standards were fully met. One requirement and one recommendation were made. 2 standards exceeded the national minimum standard. What the service does well: What has improved since the last inspection? What they could do better: This care home is providing good standard of care and support. The staff team appear experienced and competent to carry out their roles. Service users told the inspector that they were well supported to make informed decisions about their lives. Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 Page 6 Only one requirement in relation to repairs to fixtures and fittings has been made during this inspection. 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 G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 4, 5. 69 Oakley Square has a Service User’s Guide to the home and an information brochure, which accurately reflect the services provided by the home. There is a planned admission process, which includes a full assessment to ensure prospective service users needs, can be met. All service users have an individual contract and licence agreement. EVIDENCE: The home has a statement of purpose, which is presented in a brochure and has been recently updated. On referral to the home each prospective service users is given a copy of the service user’s guide and relevant policies and procedures. Three individual files were seen by the inspector. Each file includes comprehensive care plans, needs assessment and up to date risk assessments. Service users told the inspector that they were able to visit the home prior to moving in and they were given appropriate information to make a decision as to whether their needs could be adequately met. Each service user has an appropriate contract and a licence agreement, which were seen by the inspector. Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 9. There is a clear care planning system in place that involves service users and provides staff with appropriate information to meet the needs of each service user. EVIDENCE: The home operates a key work system. All service users are allocated a key worker at the start of the admissions process. From the assessment and through consultation a plan of care is developed with each service user. Care plans are regularly reviewed through key work meetings. The minutes of regular key work meetings were seen recorded on service users files. These showed that individuals are supported to make informed choices and take decisions about their lives. Risk assessments seen showed that they form part of the referral and admissions process and are built on during key work session. Service users confirmed that they are involved in the decision-making processes the outcomes of which are discussed with them and recorded on file. Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14, 15, 16. Service users are able to participate in appropriate in-house and community based activities. The home ensures that each individual service user has a range of leisure activities available to them. Contact with family and friends is maintained where appropriate and service users rights are respected within the boundaries of each individual care plan. EVIDENCE: As part of the weekly structure of the home, service users are encouraged to attend local colleges, further education facilities and local day centres. There is also a range of in house activities available such as aromatherapy, shiatsu and bingo sessions. Discussion with service users confirmed they have relevant information available to them about the local community and do get involved in local events. There are opportunities for service users to participate in individual as well as group activities one group has just returned from a holiday in France. The home has a visitor’s policy, which is outlined in the service users guide to the home. Family and friends are welcome at the home. As part of their Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 Page 11 housing rights service users have a choice of whom they want to see and are able to see visitors in private. Intimate personal relationships can be maintained subject to any restrictions agreed in individual care plans. Service users rights are clearly outlined in the service users guide. Discussion with staff and service users highlighted that daily routines and house rules are designed to promote independence and freedom of movement. Service users have keys to the front door and to personal bedrooms. Members of staff are clear they do not enter personal space without the permission of the service user. Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 Arrangements are in place to meet the physical and emotional needs of each service user. Each service user has an appropriate individual medication plan. EVIDENCE: All service users are supported to take control of the management of their own health care, and are registered with a local GP of their choice. It was evident from individual care plans that the mental health needs of service users is subject to regular review through the care management approach. The home has an up to date policy on the ordering, storage and disposal of medication. The policy covers self-medication, administration of medication by staff and homely remedies. It was clear from discussion with staff that they are aware of the medication policy and understand it. Training on the administration and management of medication is available to all staff. Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 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 standard(s) 22, 23 This home has a good complaints procedure with evidence that service users feel that their views are listened to and acted on. EVIDENCE: The home has a satisfactory complaints procedure, which is known by both staff and service users. A copy is incorporated into the service user guide. There is an appropriate system in place to record and monitor complaints. In the last 12 months the home has received 10 complaints. 4 complaints have been substantiated and 6 partially substantiated. All complaints have been responded to within the 28-day timescale. No complaints have been sent directly to the Social Care Commission. The home has a whistle blowing procedure and an adult protection policy. The home also has policies in relation to handling service user’s finances. Members of staff who spoke to the inspector were aware of the procedure to follow if an adult protection issue arose. Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 27, 30. The physical standards of the home are good. Although the home is clean and comfortable throughout there are areas that need to be improved. EVIDENCE: The inspector toured the building, which was clean and hygienic throughout Communal areas of the home are safe bright and comfortable with good quality furnishings. The home is close to local shops and amenities. The inspector visited two service users rooms. The space in these rooms was adequate. The rooms were personalized and artwork and photographs were on display. There are adequate bathing and toilet facilities available in the home. Some repairs were noted during the inspection. One shower room has water damage to the woodwork. The tumble dryer in the kitchen is not connected properly and one of the service user’s rooms has a desk and vanity unit which need to be repaired or replaced. From information seen it was clear that these repairs have been reported. No dates for action have been noted. This home is not suitable for service users or visitors with mobility difficulties. Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, The numbers of staff and the skills mix ensure that service users are well supported. Members of staff receive appropriate training to meet the changing needs of the service users. EVIDENCE: There was only one staff vacancy at the time of inspection. The rota shows that there is always at least two people on duty in the home. At night there is one waking night staff and one person sleeping in. Two members of staff have completed their NVQ level 2 training and three have nearly completed. Three members of staff are undertaking NVQ level 3 in care training. The deputy manager is completing NVQ level 4 in management and the manager is completing the Registered Managers Award. Service users who spoke to the inspector confirmed that staff are accessible when needed and are always supportive. Intimate personal care is not part of the homes admissions criteria. Equinox as an organisation has a training policy. Members of staff confirmed they have individual training records. TOPPS induction training is provided for new staff. Records seen show that a range of training in respect of meeting service users needs, maintaining a safe environment and professional development is available. Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 Page 16 However from discussion with members of staff it was clear that the home would benefit from more regular refresher courses with regard to adult protection training. Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41, 42. The home is well run and service users have the opportunity to comment on the service as a whole and on their individual care. The health and safety of service users is protected. EVIDENCE: The Registered manager has an appropriate job description, is experienced, competent and able to undertake the management role of the home. The Manager is at present completing the Registered Managers Award. Staff reported that they felt supported by the management team and were able to approach them with queries and concerns. Staff felt they were able to approach the manager at any time and were confident that any contribution or suggestions they made would be well received. The home has an equal opportunities policy, which is reflected in staff practices and in the running of the home. Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 Page 18 Quality assurance and quality monitoring systems are in place and service users told the inspector that their views were listened to both in key work sessions and in house meetings. This home has a health and safety policy and members of staff have received relevant training. Servicing documents are available in respect of fire equipment checks, portable appliance testing, emergency lighting and call bell systems, up to date certificates were seen by the inspector. Water temperatures are regulated and reports show that the water has been tested for legionella. The recording of fire drills has been reviewed and records of fire drills are appropriately recorded. Oakley Square Project G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 4 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x x 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Oakley Square Project Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x 3 2 x G58 s10344 Oakley v211257 090905 Stage 4.doc Version 1.40 Page 20 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 24 Regulation 23(2)(b) (c) Requirement The Registered \Person must ensure that the repairs identified in Standard 24 are carried out. Timescale for action 14/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 35 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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