Inspection on 06/03/07 for Oakwood Hall

This inspection was carried out on 6th March 2007.

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

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

Other inspections for this house

Oakwood Hall 21/02/06

Oakwood Hall 15/11/05

Oakwood Hall 11/02/05

Oakwood Hall 27/07/04

Oakwood Hall 24/02/04

Oakwood Hall 06/08/02

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

CARE HOME ADULTS 18-65 Oakwood Hall Oakwood Grange Lane Oakwood Leeds Yorkshire LS8 2PF Lead Inspector Stevie Allerton Key Unannounced Inspection 6th March 2007 11:30 Oakwood Hall DS0000001362.V314888.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 Hall DS0000001362.V314888.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 Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakwood Hall Address Oakwood Grange Lane Oakwood Leeds Yorkshire LS8 2PF 0113 2359079 011 2350845 administrator@commlinks.co.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) Community Links Mr Paul Joseph Beckett Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 Brief Description of the Service: The home is located in a residential area of Oakwood/Roundhay in Leeds. It is within easy walking distance of a local supermarket and a parade of shops that includes banks, a post office and food ‘take out’ shops. There are also a number of pubs in the area. Service users use these facilities on a regular basis. Regular bus services are available to travel into the City centre or further afield Care is provided for up to twelve service users aged 18 - 65, who have enduring mental health problems. Qualified mental health nurses, supported by a team of mental health support workers, provide nursing care within the home. In addition, the home is supported by general and specialist local health care services. Respite care services are also provided. Accommodation is domestic in style, the home being situated in a quiet street of large and mainly detached family style houses. There are three floors to the house and service users’ bedrooms are situated on the ground and first floors. Accommodation is provided in all single rooms, comfortable and well decorated in the occupants’ own style. Several have en-suite facilities and one of the ground floor rooms has enhanced access for wheelchair users. To the rear of the house there are large, attractive and enclosed gardens. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one inspector over the course of two visits. The first visit was made without prior announcement and lasted for seven hours; this was followed up by a second visit to meet with the Manager (who had not been on duty on the previous occasion), gain access to some records that were not available to the staff, and to give feedback on the initial outcome of the inspection. Before the visit, information about the home since the last inspection was reviewed. This included looking at any notified incidents or accidents and other information passed to CSCI, including reports from other agencies, such as the Fire Officer. This information was used to plan the inspection. The inspector case tracked three service users. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of service users and staff were considered. Using this method, the inspector assessed all twenty-one key standards from the Care Homes for Younger Adults National Minimum Standards, plus other standards relevant to the visit. The inspector spent time with service users and spoke to relevant members of the staff team who provide support to them. Documentation relating to these service users was looked at. Survey forms were left for service users to complete and return if they wished; one was returned. The inspector would like to thank everyone who took the time to talk and express their views. What the service does well: The service provides a good standard of care, personal support and accommodation for people whose enduring mental health problems have not been fully met within other services. The respite service that is provided was clearly valued by those spoken to who use it. Equality and Diversity issues are given a high profile in the written information produced for service users. The opportunities to relearn or acquire new life skills prepare individuals for their return to a more independent life in the community. Support plans are comprehensive and updated as soon as there is a change. Risk is addressed throughout all daily activities and staff look at ways to minimise risk so that individuals can make their own decisions and choices. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 6 Complaints management is very good and service users say they feel confident about raising concerns if they have them. The staff team are very knowledgeable, committed and enthusiastic about their work and are well supported by planned training and supervision. The opportunity to study for higher qualifications is encouraged, demonstrating that the organisation recognises the benefits of a skilled and trained workforce. The organisation’s commitment to service user involvement ensures that individuals feel that their views count. One service user said, “I enjoy participating in residents’ interview panels and in community meetings”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Oakwood Hall is a highly specialised care setting, where the staff team have the skills and experience to deliver the service that is aimed for. The quality of the Service User Guide is very good, written in plain English and the content easy to understand. Diversity issues are given a high profile and embodied in the Service User Guide. The service aims to be accessible to all. The referral and assessment process is thorough, and improving, as the staff team have recognised where adjustments could be made, so that customer care can be improved. EVIDENCE: Referrals come from hospitals or the Assertive Outreach Teams. Oakwood Hall’s assessment and phased lead-in to the service can take a number of weeks, depending upon the circumstances of the individual and how much time they need to adjust to the new care setting. The Service User Guide is written in plain English and is easy to understand. It establishes that Oakwood Hall tries to foster a diverse culture, promotes equality and respects rights. It includes information about the assessment process, what can and cannot be provided and some house rules. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 9 The service is block-funded by Leeds Mental Health Trust and Leeds Social Services Department and is free to the individual. The service currently has two respite beds and is developing a service for younger people with dual diagnosis (drug/alcohol problems & mental illness). Telephone support is also offered to respite users. Discussion took place with a Support Worker regarding implementing a therapeutic contract with a respite user with multiple problems and who is subject to an Anti-social Behaviour Order. He will be unable to use the service if he arrives intoxicated, and this agreement will be included within his support plan. Therapeutic contracts were seen in the case files of some of the service users who were case tracked. Discussion took place with the Manager. The service is currently looking at how they can improve customer care, including the quality of their assessment work. There are five senior staff in the assessment panel. They ask for up to date Risk Assessments and CPA (Care Programme Approach) notes and now ask for information about any index offences that may have been committed, prior to even contacting the service user, so as not to get peoples’ hopes up if they have to refuse someone a place. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 10 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 excellent. This judgement has been made using available evidence including a visit to this service. Support plans are comprehensive and regularly updated in response to change. Any restrictions on freedom and choice are clearly laid out in therapeutic agreements, drawn up in conjunction with the service user. Risk is addressed throughout all daily activities and staff look at ways to minimise risk so that individuals can make their own decisions and choices. EVIDENCE: Three service users with varying needs were case-tracked, including one person who was phasing-out into his own tenancy and currently using one of the respite beds. His support plans included one specifically for his move into the flat. He confirmed the support that staff were providing, keeping his place open whilst he settles in to living more independently. Appropriate risk assessments had been completed and updated, in line with his CPA (Care Programme Approach) care plan. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 11 Other service users’ support plans provided evidence that their needs were continuously being re-assessed and documentation updated; one had a shortterm crisis plan in place, that reflected the current issues they were experiencing, another had had a new risk assessment recently completed as part of a CPA review, as a risk area for them had changed. Support plans also contained evidence of staff helping people to make their own decisions and choices, by providing information and alternatives. This was also seen during the site visit, in various interactions between service users and the staff. Information is also available about self-help and advocacy groups. Service users said that they had regular CPA reviews and support team meetings, which are meetings with their key worker and co-workers, to identify goals, look at progress being made and make sure that the support they were receiving would help them to achieve their goals Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to identify their goals and work to achieve them. The staff try to find fulfilling activities for service users to take part in, although acknowledge that some individuals remain unmotivated or find previous unhealthy life patterns difficult to break out of. The opportunities to relearn or acquire new life skills prepare individuals for their return to a more independent life in the community. EVIDENCE: Some of the support plans included weekly planners, providing a timetable for social and leisure activities. It was detailed where people need assistance from staff in doing laundry and domestic tasks. In discussion with the Manager, she felt that some people did not have sufficient structure and they were working on strengthening links with other community-based groups, such as Touchstone, which operate social groups. Staff were also applying for Leeds Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 13 Cards for some service users, so that they can access Fearnville Sports Centre nearby. There were a few service users who are musicians and there is the occasional impromptu jam session with one of the nursing staff, who had brought his own guitar in. One person takes an interest in the house cat and makes sure it is fed. There are clearly laid out rules about illegal drug use on the premises, with evidence that staff will take the appropriate action if this is found to be happening. A warning letter was seen in one file. One service user said that she would like to take part in groups in the unit, such as confidence building. She had already made a suggestion about this to the staff. Service users are involved in the house’s domestic routines, staff supporting them, if needed, in having responsibility for their own rooms, their laundry and preparing meals. There are pictorial examples of meals posted on the dining room wall for service users to vote for inclusion into that week’s menu. This is an example of good, non-discriminatory, practice. The chef produces a range of healthier eating choices and uses a lot of fresh fruit, vegetables and salad stuffs. Service users said they liked the meals. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support plans detail where personal care is needed and how support will be provided for this. Staff provide good support for service users to access health care in the community. The Service User Guide also outlines the service’ approach to dealing with stress in ways that do not damage the person’s health. The “Harm Reduction” approach within the home’s policy on illegal drugs gives service users a clear message about what support can be provided and what behaviour cannot be tolerated. The management of prescribed medication has improved since the last inspection. EVIDENCE: The staff team had recently provided end of life care to a service user, supported by appropriate community based nurses, etc. This type of work was very different to the staff’s usual remit and they said this had been a challenging and rewarding experience. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 15 Written plans showed what support people need with their personal and emotional care; service users spoken to said they felt they were well supported by the staff team, although one person said that it was difficult for some people when staff were not available during their meetings. The Manager confirmed that on Tuesday and Thursday afternoons there is either a business meeting (looking at referrals) or a staff meeting. Daily records show that support is provided over a 24 hour period and that some individuals prefer to speak with night staff; the staffing levels do allow for spontaneous work to be carried out in response to expressed need. Needs and risks are re-assessed and support adjusted, e.g., a service user at risk of falls on the stairs has been moved to a ground floor bedroom. Specialist support in the community can also be accessed, for example, a staff member working with a service user with alcohol problems has been finding out details of alcohol support groups. The service has strong links with the community support team run by Touchstone, a voluntary body. One of the service users whose file was looked at had a plan for selfmedicating. There was evidence that this was regularly evaluated. Some service users are on depot injections of drugs to control symptoms; these are given by the Community Psychiatric Nurses rather than the home’s nursing staff. One of the nursing staff went through the medication procedures, records & storage. The nurses dispense medication from bottles rather than using a predispensed monitored dosage system. More of the service users are getting involved in making appointments with their GPs (this was seen during the visit), obtaining their own prescriptions and collecting their drugs from the pharmacist. There was no evidence of stockpiling drugs as was seen at the last inspection. The present location for the medication is in a very small cupboard upstairs, which the staff find difficult to work in. Plans are in place to convert an unused room downstairs to provide a much more suitable area for clinical treatment as well as storage and dispensing of medication. There is a clear Drugs Policy outlining the service’s approach to illegal drugs. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The records that support the complaints process reflect the organisation’s commitment to both quality and equality, ensuring that no-one is being disadvantaged or treated differently. The organisation has recognised that Adult Protection training has been lacking and intends to rectify this during 2007. This should be a priority, so that staff have greater awareness of the issues and can protect potentially vulnerable people they are supporting. EVIDENCE: The service has an open approach to complaints management. The Service User Guide outlines the process and service users spoken to said they know how to make a complaint. Some have used the procedure and been satisfied with the way their concerns have been dealt with. Complaints records were looked at. Records include Equal Opportunities Monitoring Forms and monthly complaints audits, so that the service’s line managers know how concerns are being dealt with and can analyse trends. Staff training records showed that even the newest members of staff have had training in managing violent behaviour, which is also talked through during supervision. However one of the nursing staff spoken to had had no training in Adult Protection. This was confirmed by the Manager – only the Deputy and her had had Adult Protection training so far. Staff could not locate the unit’s Adult Protection Policy when asked, although this was available during the second visit. Staff were, however, able to describe what action they would take if an incident of abuse occurred. The organisation’s Training Needs Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 17 Analysis has produced a plan for 2007, which includes a focus on Adult Protection training. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building provides flexible accommodation, with plenty of room in the communal areas for people with different interests to be able to mix and join in activities or follow their own pursuits. The standard of décor has improved from last year. Whilst the premises appear to be clean and safe, some of the records could not fully support this view. The service must provide documented evidence of good food hygiene practice and the standard of electrical safety EVIDENCE: The issue of the electrical safety check has still not been resolved; it appears that neither the owner of the property nor the provider of the service has agreed who should carry this out. The electrical safety certificate ran out in August 2005. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 19 The last Fire Officer’s report from December 2005 stated that all of the fire safety precautions were up to standard. Other Health & Safety records seen indicated that checks on various systems were carried out regularly. Decorators were working in the home at the time of the visit, painting corridors and some of the bathrooms. Window restrictors have been fitted during the past year. Two of the bedrooms were seen, both providing comfortable and individual space. The larger rooms provide a bed-sitting arrangement. One of the rooms seen had an en-suite bathroom and a kettle and fridge. Communal rooms are well equipped and spacious and allow for different activities to take place at the same time without impinging on each other. The kitchen and the laundry are both well equipped. Cleaning schedules for the kitchen appeared not to have been completed for some time, the records that could be found, in the absence of the chef, being out of date. Likewise there were no up to date fridge temperature records. Some food packets in the fridge had been opened, but not labelled with the date they were opened. The Manager was aware that a new food safety document pack was being put in place with the chef, but had not yet been fully implemented. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have confidence in the staff and have good relationships with them. There are robust recruitment procedures in place, which protect service users. Induction and ongoing training ensures that staff are clear about their roles. The opportunity to study for higher qualifications is encouraged, demonstrating that the organisation recognises the benefits of a skilled and trained workforce. EVIDENCE: Personnel files were looked at for the newest members of the staff team. There was evidence of a thorough recruitment procedure in line with best practice, with application details, written references and CRB (Criminal Records Bureau) checks. The organisation is also currently re-doing CRBs for 5 of the workforce at random. Induction training records show that core competencies are assessed after the 6 months probationary period, as the employee learns the skills required for their job role. Where there were areas identified that need further work, training was also identified and provided to assist with this. Elements of Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 21 structured training during this period included Food Hygiene, Crisis Intervention and Drugs Awareness. Training is high profile and, apart from the training provided by the organisation, they will also sponsor staff on higher education courses. Two staff are currently undertaking degree courses (Health & Social Care and a Masters Degree in Counselling & Psychotherapy). Some of the nurses are also continuing with Post Graduate training, e.g. BSc modules. Service users speak highly of the staff and appreciate their skills in mental health. One woman said that she didn’t feel comfortable when there were only two male staff on duty. One of the nurses confirmed that this was sometimes a problem on night shifts; they try to arrange the rota to have a gender mix but it is not always possible. During the first visit there was opportunity to sit in on the 2pm handover between shifts, where information about the well-being of each service user was passed on to the incoming staff. Discussions took place with various staff during the course of the day. One nurse said that he liked the more clinical side of the work, particularly assessment, and there was opportunity to do more of that. Another person spoke of his role as a non-qualified Mental Health Support Worker. He had a delegated area of responsibility within the home (Health & Safety, including Fire Safety) and was booked to go on the Fire Marshall training. He had also completed 5 units of a National Vocational Qualification (NVQ) at Level 3 in Promoting Independence and was hoping to do the Certificate in Mental Health course. The Manager spoke of the frustrations staff have in getting any further with their NVQ work; there had been so many problems with the NVQ provider not sending internal verifiers that the whole initiative had fallen through and the organisation had withdrawn from the contract. An Agency Nurse was working a shift during the site visit. He said he enjoyed working here, there was a good staff team and good relationships with the service user. He said that the recent experience of providing end of life care for a former service user had really shown the depth of the relationship that person had with the staff. Other comments staff made were: “It’s a good team to work in. There’s a variety of skills”. “It’s a nice atmosphere with a great staff team” Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 22 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, 41 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Written policies support the smooth running of the service and reflect good practice, e.g., the procedure for managing service users’ finances emphasises that this is done with, rather than for, the individual. The service has policies and procedures in place to promote health and safety, with good records of safety checks. Food safety records were not as good. The issue of who is responsible for the electrical wiring check must also be resolved. The organisation’s commitment to service user involvement ensures that individuals feel that their views count. The Manager and staff team work to continuously improve the service they give and provide good quality support for the service users. Staff are positive in their approach. Overall, there is a good understanding of the equality and diversity needs of the individuals who use this service, and the staff team are able to translate this into positive outcomes for people. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Manager has been unable to progress any further to complete the Managers’ Award, due to the NVQ provider letting them down. She is currently enquiring about an Open University modular course, leading to a Certificate of Management in Health & Social Care. The Registered Manager will not be returning to his post as originally anticipated; the situation was discussed with the person acting as Manager, who was advised to apply for registration. The home is closely supported by a Line Manager, who submits monthly reports to CSCI by email, in line with the requirements of Regulation 26. These reflect service user involvement wherever possible. One service user who returned a comment card said they enjoyed participating in community meetings and on residents’ interview panels. Others spoken to during the visit said they felt they had a say in how the home was run. There are some house rules, but people said that they could see why they were needed, for everybody’s safety. Oakwood Hall’s Service Objectives for the year include “Involving and Empowering Service Users”; to be achieved by giving training and support for interviewing, strengthening feedback systems and creating a working party to review catering. The Manager and another two senior staff have recently been on Empowerment training. The organisation also has a Service User Involvement Group that one of the respite users and one of the staff attend. A newsletter is produced about the group’s activities. The organisation’s Director is to attend a staff meeting in the near future, speaking about trying to marry up CSCI’s KLORAs (Key Lines of Regulatory Assessment) with the organisation’s objectives. Some statutory and operational records were seen, including: service users’ support plans & daily records, accident records, medication records, menus, complaints records, maintenance records, fire safety records, staff records, training records, staff rotas, minutes of community meetings and service user involvement group meetings. All were found to be in good order, with information accessible, up to date and accurate. Policies and procedures were in place to support the smooth running of the service. The notification of significant events to CSCI was discussed with the Manager, as required by Regulation 37. Currently, not every significant event is notified separately, but is aggregated on the Regulation 26 report, e.g., incidents of self-harm, which at times may be an almost daily occurrence with the client group being supported, or damage or theft of property, “minor” assaults on staff, and so on. The recording of such events shows how situations have been managed and the Line Manager monitors the impact these incidents have on the service, supporting the Manager if formal notice to quit has to be given to a service user. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 24 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 4 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X 3 2 X Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 YA23 Regulation 12(6) Requirement Staff must be trained in Adult Protection procedures, to ensure that service users are safeguarded. The premises must be periodically inspected for electrical safety and a certificate issued (This is outstanding from the previous inspection, timescale not met) The registered provider must make application for a Registered Manager, so that there is a proper line of accountability. Food hygiene records must be kept, to demonstrate safe working practices. Timescale for action 01/07/07 2 YA24 23(2)(b) 01/07/07 3 YA37 8(1) 01/07/07 4 YA42 16(2)(j) 01/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 26 1 2 YA32 YA42 The registered provider should continue to pursue NVQ training for the staff, so that the national training targets can be achieved. Food, once opened, should be labelled with the date, to ensure good hygiene practice. Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oakwood Hall DS0000001362.V314888.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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