Inspection on 27/05/04 for Osborne House

Care Homes For Adults (18 ­ 65)Oscars Hotel (Osborne House)65 Vansittart Road Windsor Berkshire SL4 5BNAnnounced Inspection27th May 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Oscars Hotel (Osborne House) Address 65 Vansittart Road, Windsor, Berkshire, SL4 5BN Email address Tel No: 01753 857610 Fax No:Name of registered provider(s)/company (if applicable) Advance Housing and Support Limited Name of registered manager (if applicable) Ms Meike Weststrate Type of registration Care Home No. of places registered (if applicable) 10Category(ies) of registration, with (number of places) Learning disability over 65 years of age (10) Registration number H010000288 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 14th July 2003 Yes YES 12/6/03 If Yes refer to Part COscars Hotel (Osborne House)Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 327th May 2004 09:15 am Susan Burton Lorna SomervilleID Code084774Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMeike WestrateOscars Hotel (Osborne House)Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementOscars Hotel (Osborne House)Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Oscars Hotel (Osborne House). The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Oscars Hotel (Osborne House)Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Osborne House in Windsor is registered to provide accommodation for 10 adults with a range of learning disabilities age between 18 and 65 of both sexes. The home was an old Victorian building badly in need of renovation. Advance Housing which own the property are investing in a complete renovation of the building that has resulted in its temporary closure. It is anticipated that the works will take between twelve to eighteen months to complete. The organisation managed to find temporary accommodation nearby in Windsor which has enabled the service user group to stay together, the majority of whom have lived together since 1984. The accommodation known as Oscars Hotel is rented temporarily while the refurbishment takes place, (the hotel is closed to paying guests and has been taken over in its entirety by the organisation). Changes have been made by the organisation for the comfort and safety of the service users. The home has three floors, which now provides a small dining room, lounge and eight bedrooms for the 9 service users. All rooms except the shared have an ensuite shower room. The location of the building is a short walk away from the original home and is closer to some of the amenities and facilities enjoyed by the service users.Oscars Hotel (Osborne House)Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was an announced inspection on Thursday 27th May 2004. Due to the refurbishment of Osborne House, the inspection took place at the temporary accommodation known as Oscars Hotel. Occupation of the hotel had commenced in early March 2004 following some minor works and safety checks. It was evident that the staff team had worked very hard to ensure the disruption to the service users lives has been as minimal as possible during the move and they are commended for their efforts. This was a mostly positive inspection. There are a number of shortfalls in the standards that relate to the organisational response to requirements and actions needed rather than the direct care providers within the home. Choice of Home (standards 1- 5) 2 of the 5 standards were inspected. Neither was met. The requirements from the previous inspection in regard to the Statement of Purpose and Service User Guide had not been met. The Statement of Purpose and Service User Guide do not meet schedule and regulation. A query in regard to the insurance of service users possessions came up during the inspection, no information was available in the home to check what cover had been provided for individuals property or possessions. Individual needs and choices (standards 6 - 10) 1 standard was inspected. This was not met. A previous recommendation that the home is provided with a detailed policy on confidentiality, which gives staff procedures and guidelines to follow to protect the best interests of the service users had not been met. Lifestyles (standards 11- 17) 1 standard was inspected. This was not met. A previous recommendation that the organisation review its arrangements on how service users will be given the option of taking a seven-day annual holiday as part of their basic contract price had not been actioned. Personal and healthcare support (standards 18 - 21) 1 standard was inspected. This was met. Systems for handling medication in the home are clear and well organised. The homes medication policy has been updated to include all recommendations made after the last inspection. Oscars Hotel (Osborne House) Page 6 Concerns, complaints and protection (standards 22 - 23) None of these standards were inspected on this occasion. Environment and Recruitment (standards 24 - 30) 7 standards were inspected. 6 were met. The accommodation provided is temporarily provided at Oscars Hotel. The organisation has fitted a new kitchen and ensured that gas, electricity and heating facilities are safe and suitable. Great efforts had been made to introduce the change to the service users with visits and discussions taking place. The staff team have been sensitive in trying to match bedrooms to the needs of service users. Bedrooms were personalised and homely and included appropriate furnishings. An OT assessment had been arranged to assess the bathing facilities available within the hotel. No major changes or equipment was seen as needed. The dining room in the hotel is small but useable. There is a separate lounge with comfy sofas and a large TV. There is no lift in the hotel or call alarm systems, the manager and team had risk assessed the hotel before occupation. The staff team had worked hard to ensure the hotel was clean and ready for service users prior to occupation. On inspection the hotel was seen as clean, tidy and hygienic. Evidence of Legionella testing was not available. Staffing (standards 31- 36) 6 standards were inspected. 2 were met, 1 had a major shortfall and 3 had minor shortfalls. Job descriptions for care staff were seen in place. Staff members are made aware of the aims and values of the home on induction. Currently there is only one care staff member other than the manager taking an NVQ, the home will not with this ratio be able achieve 50 of its staff with NVQ2 or above by 2005. The manager appears to have limited management time and is not supernumary to the staffing rota. Occasionally the home has to use agency staff to cover shifts. A requirement from the last inspection that records of staff recruitment are available for inspection was not met. A staff member had been in post since January without the completion of a satisfactory CRB check and this was seen as a major shortfall. The home had a copy of its organisational training plan. Staff members were seen to be allocated future training events appropriate to the needs of the service users. There were no members of staff using the Learning Disability Award Framework, which is recommended. The manager and deputy have both received training in supervision. Staff members receive monthly supervision and have regular meetings. Detailed notes were seen recording the last meeting. Conduct and management of the home (standards 37 ­ 43)_ 7 standards were inspected. 2 were met, 1 had a major shortfall. The manager is not supernumary to the shifts; the rotas in the home did not evidence how much management time is allocated. The staff team have worked extremely hard to minimise the disruption of service users rhythms and routines. Service users appeared relaxed and happy and did not appear to be unsettled. Evidence was seen on records that service users feel able to express concerns and discuss sensitive issues with the staff team. The home was not able to evidence that effective financial management was in place; there was no business or financial plan available. The organisation had confirmed that gas and electrical systems in the home were safe. Oscars Hotel (Osborne House) Page 7 Oscars Hotel (Osborne House)Page 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 4 YA1 The home will provide a finalised and complete statement of purpose as required by the regulations and provide a copy to the NCSC and any service user that request it. The home is to produce a finalised and complete service user guide as required by the regulation and provide a copy to the NCSC and to the service users. Records of staff recruitment are to be available for inspection 12/9/0325YA112/9/03517 (2,3) schedule 4YA3412/9/03Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard The home is provided with a detailed policy on confidentiality that gives staff procedures and guidelines to follow to protect the best interests of the service users. The organisation is to review its arrangements to provide an optional seven-day annual holiday for the service users in the home. Policies and procedures within the home meet Std 40, appendix 2.2YA103 4YA14 YA40CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). Oscars Hotel (Osborne House)MET (YES/NO) Page 9 Oscars Hotel (Osborne House)Page 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 4 Schedule 1 YA1 The Registered Person shall compile a Statement of Purpose and Service User 27/7/04 Guide that meets regulation and standard and supply a copy to CSCI. Information is to be formally provided to service users or their representatives to clarify the insurance cover available for their possessions. Shift rotas are to record the management time allocated and hours actually worked. A review of management hours provided is to be undertaken. A copy of this review is to be sent to the CSCI25 (1) cYA527/7/04318 17 (3) 10YA3327/8/044YA3727/8/04519 Schedule 2 17 Schedule 3 19 Schedule 2YA34Staff are to commence employment only following the completion of a satisfactory CRB 27/5/04 check. Volunteers are to have CRB checks.617 (2) (3b) Schedule 4YA34Records of information required by regulation and schedule are to be available in the home and available for inspection.27/6/04Oscars Hotel (Osborne House)Page 11 717 22 25 (1)YA10The home is provided with a detailed policy on confidentiality that gives staff procedures and guidelines to follow to protect the best interests of the service users.27/8/048YA43Evidence that the home is financially viable 27/8/04 for its purpose is to be available for inspectionRECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * YA42YA301Evidence of Legionella testing is to be available. Training material is to be available to support the staff members knowledge base. The organisation it to review its arrangements to provide an optional seven-day annual holiday for the service users in the home. Policies and procedures within the home meet Std 40, appendix 2. There were no members of staff using the Learning Disability Award Framework A business and financial plan for the home and service is to be available for inspection.2 3 4 5 6YA33 YA14 YA40 YA35 YA43* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire YES YES YESOscars Hotel (Osborne House)Page 12 · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES YES NO NO NO NO NO YES NO YES YES NO NO YES YES NO YES 3 X 1 NO NO YES YES 6 X 27/5/04 09.15 6.5The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met Oscars Hotel (Osborne House) (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls) Page 13 0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Oscars Hotel (Osborne House)Page 14 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 1 Key findings/Evidence Standard met? The information in regard to the fees has not been provided. The requirements from the previous inspection in regard to the Statement of Purpose and Service User Guide had not been met. The Statement of Purpose and Service User Guide do not meet schedule and regulation. A copy of both documents that are to meet regulation and are reflective of the service and environment are to be sent to the CSCI within timescale.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? No new service users have been admitted; therefore this standard has not been inspected.Oscars Hotel (Osborne House)Page 15 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? There have been no new admissions to the home during the last 2 years. This standard was not inspected.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 2 Key findings/Evidence Standard met? New licence agreements for service users have been put in place. Service users were enabled to understand the agreements with pictorial guidance and support from the CTPLD team. A query in regard to the insurance of service users possessions came up during the inspection, no information was available in the home to check what cover had been provided for individuals property or possessions. The Service User Guide should include this detail, as should the licence agreement.Oscars Hotel (Osborne House)Page 16 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Oscars Hotel (Osborne House)Page 17 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 2 Key findings/Evidence Standard met? A previous recommendation the home is provided with a detailed policy on confidentiality that gives staff procedures and guidelines to follow to protect the best interests of the service users had not been met.Oscars Hotel (Osborne House)Page 18 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Oscars Hotel (Osborne House)Page 19 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 2 Key findings/Evidence Standard met? A previous recommendation that the organisation review its arrangements on how service users will be given the option of taking a seven-day annual holiday as part of their basic contract price had not been actioned.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Not inspected on this occasion.Oscars Hotel (Osborne House)Page 20 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Oscars Hotel (Osborne House)Page 21 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence Not inspected on this occasion. Standard met? XX 0Oscars Hotel (Osborne House)Page 22 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? Systems for handling medication in the home are clear and well organised. The homes medication policy has been updated to include all recommendations made after the last inspection. Clear records are kept of all medication entering the home, those administered and those leaving the home. The home now has a contract for advice with their supplying pharmacist. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Oscars Hotel (Osborne House)Page 23 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence Not inspected on this occasion. X X X X X X X Standard met? 0Oscars Hotel (Osborne House)Page 24 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists Key findings/Evidence Not inspected on this occasion. YESX Standard met? 0Oscars Hotel (Osborne House)Page 25 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Accommodation is temporarily provided for service users at Oscars Hotel. The organisation has fitted a new kitchen and ensured that gas, electricity and heating facilities are safe and suitable. There is a small dining room and a separate lounge. The manager and staff team had made a picture board to assist service users in familiarising themselves with the new accommodation. Great efforts had been made to introduce the change to the service users with visits and discussions taking place. The manager, deputy and team are to be commended for the hard work that has taken place to ensure the transition process was as smooth as it was. Service users spoken to were happy with their rooms and were seen to be enjoying the change of scenery. The location of the home makes it easier for many individuals to access local leisure facilities; the hotel is only a short distance from Osborne house.Oscars Hotel (Osborne House)Page 26 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite NO YES NO 7 7 1 1 8 XX X 1 X3 Key findings/Evidence Standard met? The staff team have been sensitive in trying to match bedrooms to the needs of service users. Photographs were displayed on bedroom doors to aid service users to find their new rooms. 2 service users had shared a room in Osborne House and continue to do so in the hotel. There is no lift in the hotel and accommodation is placed over three floors, all service users are able and mobile enough to access their rooms.Oscars Hotel (Osborne House)Page 27 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? Three bedrooms were viewed, service users were happy to show their new rooms to the inspector. Bedrooms were personalised and homely and included appropriate furnishings.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? Seven of the bathrooms in the hotel have shower rooms ensuite. The shared room has a bath. An OT assessment had been arranged to assess the bathing facilities available within the hotel. No major changes or equipment was seen as needed. Bedroom doors are lockable if service users wish to secure them. There are toilet facilities on the ground floor near to the dining room and the lounge.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The dining room in the hotel is small but useable; a new kitchen had been fitted and was seen as suitable for the service users to cook their meals. There is a separate lounge with comfy sofas and a large TV. There is an office/sleep in room on the ground floor and another office on the first floor. A laundry room has been equipped with suitable washing and drying facilities.Oscars Hotel (Osborne House)Page 28 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? The manager had organised an O.T assessment of the hotel to ensure all bathrooms and areas were safe and suitable for the needs of the nine individuals. No adaptations were required. There is no lift in the hotel or call alarm systems, the manager and team had risk assessed the hotel before occupation. The home has a very able and supportive maintenance man who will make repairs as and when needed.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 2 Key findings/Evidence Standard met? The staff team had worked hard to ensure the hotel was clean and ready for service users prior to occupation. On inspection the hotel was seen as clean, tidy and hygienic. The laundry room has information for staff on cross infection guidance. Evidence of Legionella testing was not available.Oscars Hotel (Osborne House)Page 29 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? Job descriptions for care staff were seen in place. Staff are made aware of the aims and values of the home on induction. The manager advised that staff inductions match TOPSSs specifications. The home has a volunteer who acts as advocate and will also chair service users meetings.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 2 Key findings/Evidence Standard met? Staff skills used when interacting with service users were appropriate and sensitive to the individuals need. Guidance is given to new staff on how to communicate effectively. Currently there is only one care staff member other than the manager taking an NVQ, the home will not with this ratio be able to achieve 50 of its staff with NVQ2 or above by 2005. Evidence of the trust service users have in staff was seen.Oscars Hotel (Osborne House)Page 30 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 9 X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided 242 X X X Nursing X X XXX2 Key findings/Evidence Standard met? Information above supplied by the home. The home has seven permanent members of staff and occasionally has to use agency staff to cover shifts. Two new members of staff have joined the team. The manager carries out part of the induction process and will spend time with new staff providing information and education in regard to the needs of the service users. There was no training material in the home to assist new staff with understanding the service users differing diagnoses. The manager appears to have limited management time and is not supernumary to the staffing rota.Oscars Hotel (Osborne House)Page 31 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 1 Key findings/Evidence Standard met? A requirement from the last inspection that records of staff recruitment are available for inspection was not met. There was no evidence that recruitment information required by regulation had been seen by the home. Records were not available in the home for inspection to evidence a thorough recruitment procedure was in place to protect service users. The organisation had written to the manager stating that information was available at its central services in Oxford, this practice does not enable the home to meet schedule 4 where evidence of copies of passports and birth certificates are to be available for inspection. A staff member had been in post since January without the completion of a satisfactory CRB check. The Responsible Individual was made aware formally of the situation following the inspection and the organisation has since made arrangements to provide supervision for the individual until a satisfactory check is in place. Volunteers are to have CRB checks also. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The home had a copy of its organisational training plan. Staff members were seen to be allocated future training events appropriate to the needs of the service users. The manager advised the inspector that induction followed TOPSS specifications. New staff members had completed their inductions and had received training in manual handling, first aid and fire. There were no members of staff using the Learning Disability Award Framework which is recommended. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? The manager and deputy have both received training in supervision. Staff members receive monthly supervision and have regular meetings. Detailed notes were seen recording the last meeting. Staff can access whenever needed the local Community Team for People with Learning Disabilities, Occupational therapists and Community nurses.Oscars Hotel (Osborne House)Page 32 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO 2Key findings/Evidence Standard met? The manager is making progress with her Registered Managers award.The manager is not supernumary to the shifts; the rotas in the home did not evidence how much management time is allocated to the manager or how much time is actually worked on management tasks. A review of management hours is recommended.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 4 Key findings/Evidence Standard met? The home appears to have an open friendly atmosphere. Evidence was seen on records that service users feel able to express concerns and discuss sensitive issues with the staff team. Staff have regular supervision and meetings and are given the opportunity to try new things or take on new tasks. Service users have regular meetings chaired by a volunteer, key worker sessions and one to one time and were enabled to express any concerns. The staff team have worked extremely hard to minimise the disruption of service users rhythms and routines. Service users appeared relaxed and happy and did not appear to be unsettled. A letter from a relative was very positive and supportive of the way the manager and the team had handled the move, which potentially could have been very traumatic for some service users.Oscars Hotel (Osborne House)Page 33 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? The organisation conducts a very detailed annual quality assessment with the help of the volunteer advocate. The results of the survey could not be located since the move. A health & safety audit is undertaken on a monthly basis. The home had available an annual team plan with objectives and targets which were appropriate for the service.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 2 Key findings/Evidence Standard met? The homes policies had been reviewed and updated with staff signing to confirm they have read them. A recommendation that the home provide staff with a detailed policy on confidentiality as listed in Appendix 2 was not in place.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met ? The lack of recruitment information as required by regulation and schedule was not in place. The home was not able to evidence that effective financial management was in place; there was no business or financial plan available. Therefore this standard was not viewed as met.Oscars Hotel (Osborne House)Page 34 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The move from Osborne House to Oscars hotel had required the organisation to confirm that gas and electrical installations were safe, that the heating system was checked, a kitchen was fitted that satisfied Environmental Health, mixer valves fitted to ensure safe water temperatures. All of this was complied with. An appropriate fire risk assessment was seen.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 1 Key findings/Evidence Standard met ? The manager was not able to produce any evidence of the homes financial viability. There was no business and financial plan for the home and service that was open to inspection. There were no systems in place to evidence financial planning, budget monitoring and financial controls. It is required that evidence of the homes financial viability is available for inspection to ensure that it is able to achieve the aims and objectives set out in the Statement of Purpose. It is recommended that a business and financial plan for the home and service be available for inspection.Oscars Hotel (Osborne House)Page 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateSue Burton Lorna SomervilleSignature Signature Signature10/06/04Oscars Hotel (Osborne House)Page 36 Public reports It should be noted that all CSCI inspection reports are public documents.Oscars Hotel (Osborne House)Page 37 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 27 May 2004 of Oscars (Osborne House) and any factual inaccuracies: Please limit your comments to one side of A4 if possible This report is a very good reflection of the visit. We do not have a comment box. This box was used in the past for advocacy, when we had a more able user group. It is not used at all now.Action taken by the CSCI in response to provider comments: Oscars Hotel (Osborne House) Page 38 Amendments to the report were necessaryYESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. ,You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Oscars Hotel (Osborne House)Page 39 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Oscars (Osborne House) confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Oscars (Osborne House) am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Oscars Hotel (Osborne House)Page 40 - 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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