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Inspection on 05/09/07 for Oakwood Court

Also see our care home review for Oakwood Court for more information

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 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home 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. Good care planning practices ensure that the service users are able to make decisions for themselves and develop their independence, confidence and autonomy. Very positive feedback was received from the service users about the quality of service provided. The service users lead active and stimulating lives at Oakwood Court and gain in confidence and independence during their time there. Service users have a choice of meals at lunchtime and are helped to plan and prepare their own breakfast and evening meal. The amount of help that service users receive with their personal care is based on their individual needs and reviewed regularly to encourage independence and autonomy. Trained staff administer the service users medication safely, although more might be done to encourage self administration. The complaints procedure is accessible to the service users in an easy read format and the service users can discuss any complaints or concerns they have with the staff. The service users are protected from the threat of abuse. Service users have their own bedrooms and some bedrooms have en-suite facilities. The service users have keys to their bedrooms so that they can store their personal possessions safely. A self contained flat is available for one service user. The shared kitchen/dining room and lounge provide comfortable and functional communal rooms. A games room in the cellar and the gardens provide additional social space. The staffing levels are high enough to meet the needs of the service users and the ethos of the service, which is to encourage self-development. A quality assurance system is in place and annual development plans are produced. The service is well managed and there is a strong ethos, which is to help and encourage service users to develop their independence and confidence.

What has improved since the last inspection?

Fire doors are no longer being wedged open. An application has been received to register a manager.

What the care home could do better:

For added security an inventory should be kept of service users personal belongings. Students must be given a copy of a Service Users Guide that contains all of the required information. To avoid errors personal spending money held for service users and associated records must be checked regularly. PRN medication should be clearly recorded on the MAR sheets and the meaning of any additional codes used to indicate why an item of medication has not been administered should be identified on the medication administration record sheets. For reasons of hygiene hand-washing facilities should be provided in the communal toilets. The practice of staff working double shifts should be reviewed as overtiredness could have a detrimental effect on the quality of care provided for service users.Two references must be obtained for each new member of staff to ensure that they are suitable to work with the service users. Accessible evidence must be kept to demonstrate that POVA, POCA and CRB checks have been carried out. The identification of the staffs training needs and the provision of training could be improved to ensure that the staff, both individually and collectively, have the knowledge and skills they need to meet the diverse needs of the service users. Regular monthly monitoring visits should be carried out by or on behalf of the registered service provider. To ensure the home is safe for the residents, regular maintenance checks on gas, electrical and fire fighting and detection systems must be carried out and recorded.

CARE HOME ADULTS 18-65 Oakwood Court 7-9 Oak Park Villas Dawlish Devon EX7 0DE Lead Inspector Judy Hill Unannounced Inspection 5 & 6 September 2007 9:45 th th Oakwood Court DS0000003765.V344050.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.V344050.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.V344050.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 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 and Care (Devon) Ltd Vacancy Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. LD aged 16 - 25 years Date of last inspection 26th September 2006 Brief Description of the Service: Oakwood Court College is a privately run educational and care service for students with a learning disability aged 16 up to 25 years old, owned by a Education & Care (Devon) Limited in Dawlish. Oakwood Court College is also Inspected by the Office for Standards in Education (OfSTED) and the Adult Learning Inspectorate (ALI). The College received an annual assessment visit in June 2006 but there most recent full Inspection was in May 2005 and the report can be obtained at: www.ofsted.gov.uk. Oakwood Court provides residential accommodation and care for students who attend Oakwood Court College. Most of the students 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. The premises are situated in Dawlish, within walking distance of the town centre and bus and train routes. 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. 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). Extended placements current range: £511.25 to £1683.00 per week. The fees do not cover personal items, such as clothing or a weekly personal allowance. Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and was carried out by one inspector on 5th & 6th September 2007. The information contained in this report was gained in conversation with service users, the staff on duty, the Head of Residential Support Services and the Responsible Individual. Additional information was gained from an Annual Quality Assurance Assessment (AQAA), which had been completed by the Head of Residential Services, the Student Information Pack and from records, including student assessments and care plans, staff training and recruitment records, medication administration records and some policies and procedures. A full inspection of the accommodation was carried out. 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. Good care planning practices ensure that the service users are able to make decisions for themselves and develop their independence, confidence and autonomy. Very positive feedback was received from the service users about the quality of service provided. The service users lead active and stimulating lives at Oakwood Court and gain in confidence and independence during their time there. Service users have a choice of meals at lunchtime and are helped to plan and prepare their own breakfast and evening meal. The amount of help that service users receive with their personal care is based on their individual needs and reviewed regularly to encourage independence and autonomy. Trained staff administer the service users medication safely, although more might be done to encourage self administration. The complaints procedure is accessible to the service users in an easy read format and the service users can discuss any complaints or concerns they have with the staff. The service users are protected from the threat of abuse. Service users have their own bedrooms and some bedrooms have en-suite facilities. The service users have keys to their bedrooms so that they can store Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 6 their personal possessions safely. A self contained flat is available for one service user. The shared kitchen/dining room and lounge provide comfortable and functional communal rooms. A games room in the cellar and the gardens provide additional social space. The staffing levels are high enough to meet the needs of the service users and the ethos of the service, which is to encourage self-development. A quality assurance system is in place and annual development plans are produced. The service is well managed and there is a strong ethos, which is to help and encourage service users to develop their independence and confidence. What has improved since the last inspection? What they could do better: For added security an inventory should be kept of service users personal belongings. Students must be given a copy of a Service Users Guide that contains all of the required information. To avoid errors personal spending money held for service users and associated records must be checked regularly. PRN medication should be clearly recorded on the MAR sheets and the meaning of any additional codes used to indicate why an item of medication has not been administered should be identified on the medication administration record sheets. For reasons of hygiene hand-washing facilities should be provided in the communal toilets. The practice of staff working double shifts should be reviewed as overtiredness could have a detrimental effect on the quality of care provided for service users. Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 7 Two references must be obtained for each new member of staff to ensure that they are suitable to work with the service users. Accessible evidence must be kept to demonstrate that POVA, POCA and CRB checks have been carried out. The identification of the staffs training needs and the provision of training could be improved to ensure that the staff, both individually and collectively, have the knowledge and skills they need to meet the diverse needs of the service users. Regular monthly monitoring visits should be carried out by or on behalf of the registered service provider. To ensure the home is safe for the residents, regular maintenance checks on gas, electrical and fire fighting and detection systems must be carried out and recorded. 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.V344050.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.V344050.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 the home and the quality of 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 it sends to potential students, parts of which include symbols. There is also a Statement of Purpose that reflects Oakwood Court is part of the wider services provided by Oakwood Court College. The much of information required and recommended to be included in a Service User’s Guide is made available to the service users in an easy read format but this document needs to be amended as it is not comprehensive and copies need to be given to each of the service users. In the report of the previous inspection it was recommended that an inventory be kept of the students personal possessions. This record is still not being kept. Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 10 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 is 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 the service users first year at Fairfield House. The initial assessment process was seen to involve significant input from professionals, family and the student themselves. Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. 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: This inspection was carried out on the day before and the day of the new academic year and most of the students seen and spoken with were either in the process of moving into Oakwood Court from Fairfield House or in the process of moving out of Oakwood Court and into self contained flats for their third year. One of the students care records looked at in depth (case tracked) and provided evidence of detailed care planning and regular reviews. The records provided clear evidence of the importance that the service attaches to enabling Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 12 the service users to develop and gained their confidence and independence through the setting and achievement of personal goals. Comprehensive risk assessments were seen with risk management guidance for the individual service user and staff. Daily records were seen to be clearly written and informative. Evidence was seen of regular reviews, including annual reviews and end of term reviews. Student quote: “The staff have helped me to become more confident and not afraid to stand up for myself.” Decision-making is a key part of the curriculum at Oakwood Court College, and it was evident through talking to students and reading records that students are supported to make all the decisions about what they do including what they eat, what they do for recreation and much bigger decisions about their life styles and where they want to live after College. The staff provide assistance for some of the service users who need help to manage their personal spending money. One record of money kept by the staff for a resident was inspected and found to contain an error in calculating the running balance. Although this was only for twenty pence, it had not been picked up when the balance and records were checked. In addition to this £10 was recorded as missing. Oakwood Court DS0000003765.V344050.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. Students lead active and stimulating lives at Oakwood Court 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: Students are at Oakwood Court College for up to three years and in this time have a curricular and extra-curricular timetable during term time. Time at Oakwood Court is also used to assess and develop independence skills so all household chores are done by the students. The daily routines are governed by what students want and need to do to gain skills. Examples of this seen during the inspection included a student and member of staff building flat pack furniture and a student and member of staff cleaning a communal shower room. Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 14 The daily records completed by the staff provided evidence of daily outings that had been supervised by staff during the college holidays. These outings included trips to the Paignton Zoo, Minehead Butlins and shopping trips to Torquay. Students were asked what other activities they did in the evenings and at weekends and said youth club, football, Duke of Edinburgh Award, Karaoke, listening to music, watching TV, swimming, bowling, going to the cinema and kick boxing. During the inspection students were seen playing pool and relaxing with their friends in the basement of the college. Many of the students at Oakwood Court go into Dawlish unsupervised, while others are shadowed by staff or go out with other students. The level of support each student needs is calculated through individual risk assessments and these are kept under review. Many students go back to their parent’s houses during holiday periods others stay at the College. Students can phone or e-mail their friends and relatives whenever they like. Students spoken with said that they did their own food shopping and prepared their own breakfasts and evening meal, with support from the staff if necessary. Two of the students spoken with had a good understanding of healthy eating and said that they preferred low fat food. The main meal of the day is prepared for the students and served in Oakwood Court College canteen. Conversations with students provided evidence of choice. Student quote: “The College meals are really nice. On Fridays there is always a choice of fish and chips or baked potato and salad, but I prefer pie and chips and this is made for me”. Oakwood Court DS0000003765.V344050.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 health and personal care support enable students to develop their independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Personal support takes the form of prompting, encouragement and supervision, with some students requiring more than others. Personal care and healthcare support is documented in care plans, with goals set to develop independence. Students have fairly structured timetables during the week, which necessitate learning to get up on time, and going to bed to get enough sleep for the next day, however students are encouraged not forced to get up and go to bed. Students dress as they wish, and part of their independence training can be shopping for clothes and getting their haircut. Students are registered with a local G.P whilst at College. Dental, optician and audiologist appointments are generally arranged by parents for when student go home during the holidays. Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 16 At present only one of the students at Oakwood Court manages their own medication and it was suggested that more could be done to encourage other students to accept this responsibility. The medication administered by the staff is stored in a locked cupboard in the staff room and a suitable storage facility is provided for controlled drugs. The medication administration records were seen to be signed and up to date. It was observed that medication administered on when needed/PRN basis is not always clearly identified as such on the information sheet. It was also observed that a new code had been added to identify when medication had not been taken and this code needs to be included in the definitions at the bottom of the medication record sheets. Oakwood Court DS0000003765.V344050.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. Staff listen to student concerns and act on them and students are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure, in an easy read format, is posted on the student notice board in the home. Five of the students were asked if they would know what to do if they wanted to make a complaint and all of them said that they would speak to a member of staff. The Head of Residential Services said that no complaints had been received in the last year and the Commission has not received any complaints during this period. Most of the staff have received Protection of Vulnerable Adult training (POVA) and Protection of Vulnerable Children (POCA) training and arrangements are being made to provide this training for all staff. Policies and procedures are in place to protect service users from the threat of abuse. The Head of Residential Services said that he had a special interest in protection issues and had applied to attend a training course to qualify him to provide protection training. Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 18 Four of the service users were asked if they felt safe at Oakwood Court and if they had felt that they were being bullied. All four service users said they felt safe or very safe and that they were not being bullied. Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. The accommodation provided is suitable for student use. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of Oakwood Court found the premises to be a little chaotic however this was considered acceptable as rooms were being prepared for the new intake of students and/or were being used on a temporary basis by students waiting to move into their new accommodation. Each of the students has a single bedroom and most have en-suite facilities. There are two communal bathrooms one for women and one for men, a women only shower room and a men only wet room. There are two communal toilets, which do not have hand-washing facilities. Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 20 One of the students has a self-contained flat, which he showed the inspector around. Each of the students is given a key to their room. The students share a lounge and a kitchen/dining room, both of which were seen to be comfortable and homely. The laundry facilities were sufficient with space for students to go in and do their own laundry. Two staff members sleep in at night and suitable accommodation is provided in a designated sleeping in room and in the office. 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.V344050.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, 33, 34 & 35 Quality in this outcome area is adequate. The service users are supported by a dedicated and enthusiastic staff team, however, there are gaps in the provision of staff training and the staff recruitment process could be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records of staff training and conversations with the staff on duty identified that although some training has been provided, the identification of the staffs training needs and provision of training could be improved. For example, care is provided for people who are epileptic and people with diabetes but none of the staff who were spoken with had received training on these conditions. The AQAA identified that only two of the staff had completed an National Vocational Qualification (NVQ) in Care at Level 2 or above. The Head of Residential Services said that this was because of problems with the NVQ Assessment service and that staff had been enrolled on a fast track course to attain this qualification. Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 22 Four of the staffs recruitment records were inspected. All four staff members had completed an application form and attended an interview. The names and addresses of referees had been provided but one of the staff files only contained one reference and one contained only one suitable reference. CRB checks had been carried out. The Head of residential Services said that POVA and POCA checks had been carried out but there was no evidence to support this on the files. Forms of identification, evidence of an initial induction and contracts were found in each file. Conversations with the staff on duty and Head of Residential Services indicated that the staffing levels were high enough to meet the needs of the service users. However, it was observed that the staff often work a double shift (9am to 11pm) followed by a sleep in followed by a second double shift (7am to 10pm). This is not good practice as the staff could become overtired and unable to perform their duties efficiently. The staff receive regular one to one supervision and a team leader is on duty throughout the day to provide informal supervision and support. As Oakwood Court is situated on the same site as Oakwood Court College and assess to the service users living accommodation is quite open, it is suggested that the staff are issued with visible identity cards. Oakwood Court DS0000003765.V344050.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 adequate. The quality of the service provided for service users is generally very good, but the lack of available evidence that routine maintenance checks are being carried out raises concerns about the safety of the premises. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is currently no registered manager in post but an application has been received to register the Head of Residential Services as manager. The duties of a manager are currently being carried out by the Head of Residential Services and by a deputy manager and these is no indication that the Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 24 temporary absence of a registered manager is having a detrimental effect on the quality of the service provided. Discussions with the Responsible Individual and the Head of Support Services identified that monthly monitoring visits are not being carried out on behalf of the registered service providers. The Responsible Individual has developed a Quality Assurance system. The Learning Skills Council give advice and guidance to the College on Quality Assurance, and a regular self-assessment is carried out which gathers the views of students, staff, placing local authorities and parents. A three-year development plan is also produced. Most of the required and recommended policies and procedures are in place and were reviewed in April 2007. These are kept in the staff office and available for the staff to read and refer to. The registered persons do need to provide a written policy on “Discharge of service users, including planned discharge and termination or self-discharge at short notice” and “Emergencies and Crises”. Although requested, no dates were given to indicate that regular maintenance checks and services are being carried out on gas and electrical appliances and no records were seen to provide evidence of maintenance tests. Oakwood Court DS0000003765.V344050.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 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 2 X 3 X X 2 X Oakwood Court DS0000003765.V344050.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 YA1 Regulation 5 Requirement Students must be given a copy of a Service Users Guide that contains all of the required information. A copy must also be sent to the Commission. Two suitable references must be received before employing staff to work with the service users. The staff must receive training that is appropriate to the work they are to perform. Monthly monitoring visits must be carried out on behalf of the registered service provider and reports must produced on the conduct of the home. Timescale for action 05/12/07 2. YA34 19 05/12/07 3. 4. YA35 YA37 18 26 05/05/08 05/10/07 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 YA1 Good Practice Recommendations An inventory of each student’s possessions should be kept. DS0000003765.V344050.R01.S.doc Version 5.2 Page 27 Oakwood Court 2. 3. YA7 YA20 To avoid errors personal spending money held for service users and associated records must be checked regularly. PRN medication should be clearly recorded on the MAR sheets and the meaning of any additional codes used to indicate why an item of medication has not been administered should be identified on the medication administration record sheets. Hand washing facilities should be provided in the communal toilets. At least 50 of the care staff should have an NVQ in Care at Level 2 or above. The staff should not work double shifts as this could affect their performance. Evidence should be kept in the staff files to show that POVA, POCA and CRB checks have been carried out. Up to date records of Health & Safety checks should be kept in the home. The maintenance and renewal issues identified during this visit should be included in the Home’s programme. 4. 5. 6. 7. 8. 9. YA24 YA32 YA33 YA34 YA42 YA42 Oakwood Court DS0000003765.V344050.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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