CARE HOME ADULTS 18-65
Oakwood Court 7-9 Oak Park Villas Dawlish Devon EX7 0DE Lead Inspector
Judy Hill Unannounced Inspection 14 & 15th July 2008 11:00
th Oakwood Court DS0000003765.V365027.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 Oakwood Court DS0000003765.V365027.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. Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Oakwood Court Address 7-9 Oak Park Villas Dawlish Devon EX7 0DE 01626 864066 01626 866770 admin@oakwoodcourt.ac.uk 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) Education & Care (Devon) Limited Vacancy Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. LD aged 16 - 25 years Date of last inspection 5th September 2007 Brief Description of the Service: Oakwood Court is registered to provide accommodation and care for a maximum of twelve people who have learning disabilities. The people who use this service are students at Oakwood Court College. Oakwood Court College is an independent special needs college that provides three year residential courses for people aged between sixteen and twenty-five who have learning disabilities. The college is inspected by the Office for Standards in Education (OfSTED) and the Adult Learning Inspectorate (ALI). Most of the people who live at Oakwood Court are second or third year students and most have transferred from their first year accommodation, which is provided at Fairfield House. The college term time is thirty-eight weeks and although some students remain at Oakwood Court during the college holidays, most return to their permanent homes for this period. The residential facilities take up the first floor of the Colleges main educational building and are accessible by stairs or by shaft lift. Oakwood Court is in the pretty seaside town of Dawlish and is within walking distance of the beach, town centre, bus services and train station. Information about Oakwood Court College is provided in the form of a Student Information Pack and this includes information about the accommodation and care provided at Oakwood Court and Fairfield House. Copies of the information pack and the homes inspection report can be obtained from Oakwood Court College on request. The fees, which are LSC funded, cover the costs of college fees as well as student care and accommodation and currently range from £36,772 to £67,775 (term time only). Extended placements can be arranged to cover college holidays at a cost of £749 a week plus £19 an hour for additional care. The fees do not cover personal items, such as clothing or a weekly personal allowance. Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use the service experience good quality outcomes.
The site visit for this key inspection was unannounced and was carried out on the 14th and 15th July 2008 by one inspector. The information contained in this report was gained from observation and from conversations with some of the people who use the service, the Head of Residential Services and some of the staff on duty. Information was also taken from a spot check of records, including samples of resident’s assessments and care plans and staff recruitment and training records. Additional information was gained from the colleges Statement of Purpose and Students Charter, from an Annual Quality Assurance Assessment and from surveys that were completed and returned by seven of the people who use the service. What the service does well:
The initial and on-going assessments of the service users individual needs are very thorough and provide a good basis for individual care planning. The people who use the service are involved in their care planning and are encouraged to set personal goals, make decisions and maintain and develop their independent living skills. The people who use the service are actively encouraged to lead full and active social lives, be happy and have fun. The people who use the service receive as much or as little help with their personal care as they need and their physical and emotional health is monitored discretely. Concerns and complaints are taken seriously and acted upon and measures are in place to protect the people who use the service from the threat of abuse. The people who use the service have their own bedrooms and their privacy is respected. The staffing levels are maintained at a level that is adequate for the needs of the people who use the service and the staff support and encourage people to do things for themselves rather than have things done for them. Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 6 The service is well managed and provides a safe and enabling home environment for the people who live there. What has improved since the last inspection? What they could do better:
To provide evidence that the people who use the service are actively involved in their care planning, records should be signed by person making the record and the person the record is for and dated. The registered persons must ensure that all medication is administered as prescribed. Although the countersigning of the medication administration record sheets by the people using the medication is recognised as good practice, the registered persons should ask the pharmacist to provide sufficient space on the sheets to facilitate this as the current arrangements make the sheets difficult to read. The registered persons must upgrade the bathrooms, shower rooms and toilets so that they can be kept clean and hygienic. At least 50 of the care staff should have an NVQ in Care at Level 2 or above. The collective and individual training needs of the staff, including induction and foundation training, should be identified and met. The person appointed as manager must submit an application to be registered. Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 7 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. Oakwood Court DS0000003765.V365027.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 Oakwood Court DS0000003765.V365027.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 Quality in this outcome area is good. Care is taken to ensure that the people moving into Oakwood Court know about the home and the service they can expect to receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Oakwood Court College has a welcoming information pack that it sends to potential students, parts of which are presented in a picture format to make it easier for people who are considering using the service to read. There is also a Statement of Purpose and this reflects that Oakwood Court is part of the wider services provided by Oakwood Court College. In the surveys completed by seven of the people who live at Oakwood Court, six said that they were asked if they wanted to move into the home and all seven said that they had received enough information above the home before they moved in. Much of information that is required and/or recommended to be included in a Service User’s Guide is given to the people who use the service in an easy to Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 10 read picture format which can be understood by people with good reading skills as well as people who may find reading difficult. In the report of the previous inspection it was recommended that an inventory be kept of peoples personal possessions and this record is now being kept. Most of the people who live at Oakwood Court are second year students at Oakwood Court College and have transferred from their first year accommodation, which was at Fairfield House. As the residential accommodation is in the same building as the College, the people who move in already know about the accommodation, its location and service that will be provided. The standard of pre-admission assessment and continual assessment of students needs is high with full and detailed assessments being carried out by both the College and the placing local authority before admission. This includes a three-day assessment stay at Fairfield House and on-going assessments throughout peoples first year at Fairfield House. The initial assessment process was seen to involve significant input from professionals, family and the student themselves. Records from the first year are transferred during the summer holidays so that the staff know about the people who will be moving in and their needs. Oakwood Court DS0000003765.V365027.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 & 8 Quality in this outcome area is excellent. The quality of the care planning ensures that service users are able to make decisions for themselves and take risks within a safe framework. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit a spot check of some of the individual plans of care (needs assessments, care plans, reviews and risk assessments) written up and developed with the people who use the service was carried out. These provided evidence of detailed care planning and regular reviews. The records that were seen provided clear evidence of the importance that the service attaches to enabling the people who use the service to develop and gain confidence and independence. This is done by setting individual goals for people to work towards achieving. The records seen suggest that the people who use the service are directly involved in their care planning and reviews
Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 12 and in the setting personal goals. However, some of the records seen had not been signed or dated, either by the staff or the resident involved. Most of the people who live at Oakland Court were seen during the site visit, three of them were engaged in conversation in private and seven of them completed and returned surveys to the Commission. In the surveys that were completed by seven of the people who use the service all of them said that they could do what they wanted in the evening and six said that they do what they want at week-ends. One respondent said that “Staff ask all students what they would like to do in meetings.” All of the people seen during the site visit were approaching the end of their second or third years at the college and the aims of the service, to encourage people to develop and improve their life skills and do as much as they can for themselves, had clearly been put into practice. One person was seen ironing, others relaxing in the TV lounge or in their bedrooms and some were busy packing ready to leave for their summer holidays. Several residents showed us their bedrooms, all of which were seen reflect their own interests and hobbies. All of the people who use the service are able to manage their own personal spending money but the home does provide storage facilities for keeping money safe and secure if the people who live at the home choose to use them. Some of the records of the personal spending money held for safekeeping were seen and the money kept was checked and both tallied. Oakwood Court DS0000003765.V365027.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 excellent. The people who live at Oakwood Court lead active and stimulating lives at and gain in confidence and independence during their time there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The people who live at Oakwood Court attend classes at the College from Monday to Friday. Some of them also have part-time jobs through the Work Placement Scheme and the Head of Residential Services said that at least one of the third year students had been offered a permanent job when she leaves college as a direct result of this. The people who live at Oakwood Court spend their evenings and weekends developing their independent living skills by choosing and preparing their own meals and carrying out household chores, such as cleaning, doing their laundry
Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 14 and ironing. This leaves them with time to attending evening classes, go out and/or participate in social activities at home, or just relax and watch television, listen to music or play computer games. The following range of social activities and evening classes that the people at the home participate in was provided by some of the people who live at Oakwood Court: driving lessons, yoga, kick boxing, swimming, tae kwon do, cycling, basketball, football, horse riding, trampoline, bowling, quasar, dance, drama, paperwork, practical skills, money skills and participation in the Duke of Edinburgh Award. All of the students make their own breakfast and evening meal, do their own laundry and keep their own rooms and the communal areas clean with as much or as little help as they need from the staff. One of the people spoken with said that she had completed her three year college course and that she had enjoyed it so much that she would be starting another college course at a different residential college in September. Another person said he had completed his second year at college and was looking forward to coming back in September because he would be moving from a bed-sitting room to a flat and that this would give him more independence. Several of the residents frequently go out without a staff escort but if support is needed it will be provided. Most of the people who use the service spend their college holidays with their parents or guardians. Prospected residents and their parents and guardians must visit the home and college prior to admission and the people who live at Oakwood Court are free to invite their families and friends to visit them during their stay. Assistance will be given, if it is needed, to help the residents keep in contact with their families and friends by letter and phone. The right of the residents to choose their own friends is included in the Students Charter. Oakwood Court DS0000003765.V365027.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 good. The people who live at Oakwood Court receive as much or as little help with their personal and healthcare as they need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The level of help that each person needs to assist them with their personal care is assessed as part of the admissions process and regularly reviewed. As one of the stated aims of the service is “…to provide an enabling atmosphere for vulnerable youngsters…” the emphasis is based on developing individual skills and only providing the level of support that people need. A key worker system is in place to enable each of the residents to identify closely with a named member of staff is in place and one of the people spoken with said that if she had any problems she would talk to her key worker. The healthcare needs of the people who live at Oakwood Court are monitored but arrangements for regular healthcare checks, such as visits to the dentist or
Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 16 optician, are usually arranged by parents or guardians to take place during the college holidays. The psychological and emotional needs of the residents are also monitored either through key workers or the staff on duty and during the site visit a member of staff was seen comforting and reassuring a resident who was upset. Most of the people who use medication are given help by the staff to make sure that they take it safely and this may be an area where, subject to individual risk assessments to ensure that appropriate safeguards are in place, some of the residents could be given more autonomy and control. The medication administered by the staff is kept in a locked cupboard in the staff office. Suitable facilities are provided for the safe storage of controlled drugs. The medication administration record sheets were seen and in most cases the records had been signed by the member of staff assisting with the administration of the medication and the person taking it. This is recognised as good practice but it did make the record sheets hard to follow and it is therefore suggested that an approach is made to the pharmacist to ask if the record sheets can be modified. One error was spotted on the medication administration sheets. Eye drops that were prescribed to be taken four times a day were only being administered twice a day. We were told that the resident had not suffered any ill effects from this error but a visit to the GP is advised to review the situation and if necessary alter the prescription. Oakwood Court DS0000003765.V365027.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 good. Any concerns, complaints and/or allegations made by the people who use the service or their representatives will be taken seriously and appropriate action will be taken. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is presented on a notice board in the home in a picture format to make it easier for the residents to understand. The Head of Residential Services said that the complaints procedure was talked through with the residents during meetings and tutorials and in additional to raising complaints with the management and staff, complaints could be made in writing to the Students Council. The surveys completed and returned to the Commission by seven of the people who use the service told us that although not all of them know and understand the Complaints Procedure, all of them know that if they are not happy about something they can talk to the staff. The Commission has not received any complaints about Oakwood Court in the past year and only one complaint was recorded in the homes ‘Complaints’ book.
Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 18 The Home provides care for people who are as young as sixteen and therefore all new staff are checked against both the Protection of Vulnerable Adults (POVA) and the Protection of Vulnerable Children (POCA) lists before they start working at the home. Some of the staff have received Protection of Vulnerable Adult training (POVA) and the Head of Residential Care Services said that he was planning to ensure that this training and Protection of Vulnerable Children (POCA) training is provided for all staff and updated annually. Policies and procedures are in place to protect the residents from the threat of abuse and the Annual Quality Assurance Assessment identifies that there are plans to review these and to bring them into line with the local authorities new Safeguarding Procedures. The management have demonstrated that they understand their responsibilities under the Safeguarding Protocols and take these very seriously. They have made three safeguarding referrals to the local authority in the past year. Two of these did not relate to incidents are alleged to have occurred at or involved the staff at Oakwood Court. The third relates to an allegation made against someone who used to work at the home, but has since left and this matter is still being investigated by the police. Oakwood Court DS0000003765.V365027.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, 27 & 30 Quality in this outcome area is adequate. The accommodation is spacious and the layout suits the needs of the residents both collectively and individually. However, the bathrooms, shower rooms and toilets need attention to ensure that they are safe and hygienic for the residents to use. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Oakwood Court is in the small seaside town of Dawlish. Oakwood Court College occupies the ground floor of the building and residential accommodation for twelve students is on the first floor. The students share a comfortable lounge and a kitchen/dining room and these rooms were seen to be adequate for their needs. Each of the students has their own bedroom and one has a self-contained flat. Three of the students showed us their bedrooms and these were seen to be
Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 20 very much their own private space, as they clearly reflected their interests and individual personalities. The students have keys to their bedrooms. Although most parts of the home could benefit from general refurbishment, communal rooms and bedrooms were seen to be clean and to meet the needs of the people using them. The bathrooms, shower rooms and toilets do need refurbishing to bring them up to an acceptable standard in terms of hygiene. Both of the bathrooms smelt damp and mould was clearly visible on the ceiling in the wet room. The communal toilets do not have hand-washing facilities and disposable towels were not available in all of the bathrooms and shower rooms. The laundry facilities are sufficient with space for students to go in and do their own laundry. There is a staff office with secure storage facilities for private records. This room doubles as a staff sleeping in room. There are pleasant gardens for the service users to use and service users have access to a games room in the basement of the college. Oakwood Court DS0000003765.V365027.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): 32, 34 & 35 Quality in this outcome area is adequate. Safe staff recruitment practices are used and the staff were seen to work well with the students. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing levels need to be set at a level that is high to enable the staff to help the residents to develop their independent living skills by supporting them to do things for themselves rather than have things done for them and an observation of the staff and students working together on the second day of the site visit showed us that Oakwood Court had got that balance right. The feedback from the staff spoken with during the site visit was very positive and it was clear from observing the way that the staff worked with the residents that the staff on duty enjoyed their work. Further evidence of this was gained in conversation with the staff on duty. Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 22 Staff recruitment records were seen and these show that safe recruitment practices are being used to employ new staff. This process includes carrying out CRB, POVA and POCA checks and taking up written references. No evidence was seen to show that the staff have been receiving induction and foundation training that meet Skills for Care requirements. Records of staff training were seen and the quantity of training courses attended and qualifications gained vary considerably between staff. Gaps in the provision of health and safety related training, such as First Aid, Epilepsy, Basic Food Hygiene and Infection Control, POVA and POCA need to be filled and the service providers need to identify the specialist training that the staff need. The service providers also need to ensure that the staff are given opportunities to access NVQ courses as only twenty-five percent of the staff hold National Vocational Qualifications. The staff are supervised on a daily basis and are given formal one to one supervision, however the records showed that this is not currently being provided six times a year. Oakwood Court DS0000003765.V365027.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. The people who live at Oakwood Court can be confident that the service is well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the company that own and manage Oakwood Court College and the residential accommodation, Education & Care (Devon) Ltd, has been sold. The new Responsible Individual is Mr Keith Burnley and a new Head of Residential Services, who said that he would be submitting an application to be the Registered Manager of Oakwood Court, has been appointed. Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 24 The change of ownership has been sensitively managed and does not appear to have caused any upset to the people who use the service or the staff. The Annual Quality Assurance Assessment that was completed for the Commission by the new Head of Residential Services outlines a number of ways that he feels that the service can develop and improve. One of the areas outlined for improvement is quality assurance and there are plans to introduce a more defined student involvement strategy to ensure that the people who use the service can influence the way their home is run. The quality assurance systems currently in place include student meetings, staff meetings and the use of surveys to gain feedback from the people who use the service and their relatives. A periodic inspection for the electrical installations was carried out in February 2008 and a satisfactory report of this was seen. A report was also seen to show that the gas appliances had been tested in October 2007. The AQAA identifies that fire detection and fire-fighting equipment was tested in March 2008. The AQAA also tells us that written policies, procedures and codes of practice are in place and that they were last revised in April 2007. The Head of Residential Services said that some of the existing policies and procedures will be revised as part of the on-going development of the service. Oakwood Court DS0000003765.V365027.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 3 2 4 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 1 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 X X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 4 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 X 2 X 3 X X 3 X Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 Requirement The registered persons must ensure that all medication is administered as prescribed. The registered persons must upgrade the bathrooms, shower rooms and toilets so that they can be kept clean and hygienic. Timescale for action 14/08/08 2. YA27 23 14/10/08 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 To provide evidence that the people who use the service are actively involved in their care planning, records should be signed by person making the record and the person the record is for and dated. Although the countersigning of the medication administration record sheets by the people using the medication is recognised as good practice, the registered persons should ask the pharmacist to provide sufficient space on the sheets to facilitate this as the current
DS0000003765.V365027.R01.S.doc Version 5.2 Page 27 2. YA20 Oakwood Court arrangements make the sheets difficult to read. 3. 4. YA32 YA35 At least 50 of the care staff should have an NVQ in Care at Level 2 or above. The collective and individual training needs of the staff, including induction and foundation training, should be identified. The person appointed as manager must submit an application to be registered. 5. YA37 Oakwood Court DS0000003765.V365027.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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
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