Inspection on 28/09/07 for Osborne House

This inspection was carried out on 28th September 2007.

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

The inspector found 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Osborne House 20/09/06

Osborne House 07/11/05

Osborne House 12/07/05

Osborne House 07/12/04

Osborne House 27/05/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Osborne House 90 Osborne Road Windsor Berkshire SL4 3EN Lead Inspector Ruth Lough Unannounced Inspection 28th September 2007 10:30 Osborne House DS0000011278.V344718.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 Osborne House DS0000011278.V344718.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. Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Osborne House Address 90 Osborne Road Windsor Berkshire SL4 3EN 07845 996807 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) malama.pierids@advanceuk.org Advance Housing and Support Limited Mrs Malama Pieridis Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (9) of places Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2006 Brief Description of the Service: 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 is an old Victorian building, which has been completely renovated. The home is situated close to Windsor town centre and in walking distance of many local amenities. The home has 4 floors and each single bedroom has its own en-suite facilities. There are separate kitchens on each floor in addition to the communal kitchen and lounge. To the rear of the property there is a large garden. The home has wheelchair access throughout including the installation of a lift. There are small balcony areas located on some of the floors. The home is bright and airy throughout. Fees are £742 per week. Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection process that had been generated from the findings from an assessment of the service that was carried out in September 2006. This inspection process included information provided in the Annual Quality Assurance Assessment documents completed by the manager, and the surveys returned from all of the residents living in the home plus two staff members. Three relatives of the eight contacted also returned surveys. Further information was obtained during the one-day visit that included reviewing records and documents available and discussions with some of the residents and staff. What the service does well: 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. Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 6 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 Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 7 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): 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not ensure that they assess that they can offer a place to a new service user or review that they can continue to do so. EVIDENCE: The records of the assessment process for the one new resident of the home were reviewed. This was to establish if they carry out an effective process to ensure that they are able to meet their needs and that the individual will be compatible to the other people living there. The one service user had been admitted to the home in May 2007 through a referral and assessment process by the NHS community team for people with learning difficulties. Copies of this detail assessment process were with the records held in the home regarding this individual. However, there did not appear to be records of the homes assessment process to identify that they would be able to meet the service users needs or that he was suitable to be accommodated with the other residents. Details of any trial visits before admission had not been identified in the records, but staff did confirm that the service user had had the opportunity to do so. A number of the other residents living in the home had been there for a considerable length of time and it was evident that the responsible NHS Community team reviewed their needs on a regular basis and copies of these Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 8 document’s were included in their records. Again, for these individuals there was not evidence that the home had reviewed that they were still able to support them. Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 8. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The people who use the service are put at risk because of the poor quality of the documented care planning and the lack of reviewing that their needs are being met. EVIDENCE: The care and support plans for three residents were reviewed to see if the information from the local health authority/ social services assessment has been used effectively for care planning to provide support to meet their needs. The records for the service users are kept in three places. One file holds the records regarding assessments, correspondence, action plans, and some risk assessments. Additional to these are healthcare specialists reports, evidence of routine weight monitoring, notes made after significant events and contact details for the individual’s family or next of kin. A second document is used as a lifestyle plan to convey the individual’s choices and needs in a simple format for the service users to understand. Staff use a daily diary to record the outcomes for the individual about the day or a significant activity. Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 10 The quality of parts of the care planning records for the three, service user’s, were very poor in places. What was of significant concern was that one service user had been living in the home for four months and had not yet had an appropriate care or lifestyle plan in place. Staff had recorded significant information about support required during different activities such as behaviour/ risks when in public places but this and some of the health related information had not been formalised into a care or lifestyle plan. For another service user a recent change in health care was only reflected in the records in the service users daily diary and a brief statement in the main file but nothing had been altered or added to the care planning tools. What also was not clear for all three was how their learning disability/ mental health needs impacted on their lives or on others. The majority of the records seen did not give staff instruction of how to support the individual in regard to activities of daily living such as personal care, domestic and social activities. A number of the records seen had not been reviewed or re-assessed. Particularly, one care plan did not have a date recorded when it was developed and another was dated 2004 and was without any indication that it had been reviewed. One of the lifestyle plans had been created in 2002 with some evidence of amendments but the date of review or changes had not been recorded. Some of the service users, but not all, have individual time where together with the key worker they review their personal choices and wishes on a separate document and record with fairly good detail the outcomes of this discussion. However, significant changes are not reflected in the care plan documents. The care staff record information in the daily diaries in detail and it could be seen that these were used to pass significant information to each other to support the individual. The home use document tools to assess risk assessments for the individual and for activities they may take part in. The assessments seen during a review of the care records were for the individuals general activities for living in the home or personal support. However, the depth of information in some were brief or where possible risks may occur such as behaviour management, medical needs, personal safety and taking part in external activities to the home had not been carried out. It could also be seen that some of these risks had not been reviewed or reassessed as regularly as they should be with some that had been originally carried out in 2004. Staff provided further supporting evidence that risk assessments were carried out for holidays and one off activities but these were kept separate from or were not referred to, in the individuals care planning information and therefore may not give a holistic picture to staff about meeting service users needs. Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 11 What was clear when talking to staff is that they had a very good understanding and knowledge about the service users that was not reflected in the risk assessments or care planning. The arrangement or organisation of the documents in the main care planning and health history records is not user friendly. The current method of holding these could make it difficult for staff to find the relevant information, review risk assessments, and ensure they have the most recent information before they begin to support the individual concerned. This must be particularly difficult to ensure that any agency or bank staff have the correct information before they provide support. A previous requirement to improve the care planning records and risk assessments that should have been complied with in December 2006 have not been carried out. Osborne House DS0000011278.V344718.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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. That service users have an active supported lifestyle that meets their choices, ethnicity and cultural needs. EVIDENCE: The residents gave positive comments about the activities they are supported to do. They have a weekly programme of either educational, social, or personal development activities that they undertake that either takes place in the home or externally in local public or specialist educational and community centres. The documents in the care planning records about the individual’s choices and the planning and risk assessments for these were variable in quality. Residents and staff can refer to the individuals planned programme as they are on display in a communal area in the home or in the staff office. Staff informed the inspector that new personal activities programmes were in the process of being introduced. Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 13 Service users are encouraged and supported to take an active interest in what is going on in the community and to develop their skills to support themselves where possible. Some of the activities include taking greater responsibility for shopping at the local supermarket and town centre, joining local dance and drama classes and enjoying local events that occur. The home has provided the residents with holiday breaks that include small groups and individuals either supported by the staff or their families. For two people this was to go independently, at their request, just with assistance from the travel company. One resident with minimum support has recently made contact with his favourite football team. They responded to the letter he wrote and have invited him to visit the football ground where he is hoping to see a live match. However, the care planning records did not provide sufficient information about the holidays taken or reflect the development of the regular planned activities. Staff provided information to the inspector that residents were able to continue with relationships and contact with families and friends and extra support is provided when required. This was confirmed through discussion with the residents and some documentary evidence in the individual diary’s noting the outcomes of the visits or contact with relatives or friends. Staff support the residents with daily activities such as shopping, cooking, meal preparation and keeping their rooms and the home clean and tidy. Some of these activities are noted in the planned programmes for the individual, their care plans and the reviews carried out by the key worker and the person concerned. However, this is variable in quality and would not provided sufficient information to bank or agency staff should they be required to work in the home. Through discussion with the service users and staff it was apparent that they worked well together and that there were established routines that encouraged the service user to continue learning new skills to care for themselves. The documentary evidence that the nutritional needs of the individuals are part of the care planning process was not detailed enough in the care records reviewed. They do monitor their weight, usually on a monthly basis, and seek some help from health care specialists when concerns are raised but how they were to meet these needs was minimally recorded. The staff confirmed that they support individuals to plan their weekly menu and shopping and assist in the preparation and cooking of their meals. Records for this in the care planning were not seen. Staff were seen to encourage the residents to prepare their midday meal and they appeared to enjoy the social aspects of eating their meals together. If residents are able and wish to, they have the facilities to prepare meals and snacks in the small kitchens on each of the floors of the home. Osborne House DS0000011278.V344718.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 and 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not have sufficient monitoring or care planning records in place to ensure that staff are supporting service users appropriately to access and address their health care needs. EVIDENCE: The records for care planning and the lifestyle plans were reviewed to assess that the healthcare, medication, and personal support needs of the individual are being met. Through discussion with the service users and staff it was very apparent that the staff in the home are very pro- active at seeking the individuals choices of how they wish to live, encourage them to develop skills to care for themselves and ensuring that the health needs are met. This is not always reflected in the care planning and other records kept in the home. One member of staff is introducing and carrying out an assessment and planning process for the health care needs of each person. This exercise has not been completed for all the service users and will when fully implemented support staff to ensure that a more formal process to monitor their health and Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 15 give the opportunity for the individual involved through discussion with staff to take some responsibility manage their own needs. Information in the care records reviewed about the routine health checks such as dental, hearing and sight tests were minimal. It was identified through discussion with staff that one service user had some hearing loss but this was not recorded in their care planning. One relative stated in a survey returned to the commission that they were concerned that their relation did not have enough support with wearing their dentures. Some, but not all, of the medication needs of the service users are recorded in parts of their care plan records although for one, the information is brief and not necessarily recorded in a very professional manner. The documented policies and procedures for care planning, health care support, and medication were not available to staff or for inspection purposes during the inspection process. Therefore it was difficult to assess that staff adhere to the provider’s guidelines or that these meet their regulatory responsibilities. The assessment of the medication practices was carried out through observation and discussion with staff. The home uses a monitored dosage system (MDS) that is provided by a local pharmacy. Staff confirmed that none of the service users manage or administer their own medication at present. Residents are encouraged to remember that they are due medication and this process usually takes place in the office where time is taken with each individual. Medication is stored safely and staff record appropriately on the medication charts every transaction that takes place. The staff record any non- prescription medications such as painkillers or cough remedies in a separate document to the MDS record and it was difficult to assess in the records seen whether this is monitored with reference to the regular medication they take. Staff spoken to on the day confirmed that they had received specific training for medication administration. The home has obtained some information about personal choices about how the service users wish to be cared for if they become ill, as they age and their eventual death should they still be living in the home. This difficult topic has been discussed with some of the service users and their relatives and is recorded in various parts of the care documents. This is because of personal bereavement has occurred and has generated questions to be discussed and not through a planned process. The information, policies, procedures and guidance for this that should be in the home and made available to staff was not available to be reviewed. Osborne House DS0000011278.V344718.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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are confident that their concerns will be listened to and acted upon. EVIDENCE: The homes processes and records for managing concerns, complaints and possible abuse were reviewed as to assess if suitable systems in place to protect the people living in the home. Staff and service users confirmed that the complaints process had been provided to the residents living in the home in the documents about the service that they keep in their rooms. In the returned surveys from the residents the majority expressed that they knew how and who to complain to, one did not. Two of the three relatives who responded to the survey also confirmed that they knew how to make a complaint. The one relative who was not aware of the complaints process has become in the last year the responsible contact for their family member living in the home and has not been provided with a copy of this. The manager provided information in the self- assessment document (AQAA) that the home has not received any formal complaints since the last inspection process. The commission has also not been in receipt of any concerns, complaints or information about the service during this period. What was not evident is how they manage minor concerns or comments from the residents, Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 17 visitors or relatives and how they monitor these for quality assurance purposes. The home has policies, procedures, and information for staff in regard to protecting the service users from possible abuse or harm. The Safeguarding Adults policy and procedure available to staff refers to the local interagency protocols but a copy of these was not available for staff to follow or use the document tools that are included should a concern be raised. The staff spoken to during the visit confirmed that they had been provided with the necessary training for this. The manager also provided information in the AQAA that there was one safeguarding adults referral to social services, but information about this has not been sent to the commission. Osborne House DS0000011278.V344718.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a routine programme of maintenance. The home is kept clean and there are good systems in place for the control of infection. EVIDENCE: The residents and staff gave positive comments about the standard of the environment and the facilities available since the refurbishment process of the home was completed last year. The home has been upgraded to provide en-suite bedrooms on three floors with small kitchens on each one for those residents who are more able to manage to partly cater for themselves. Consideration has been made to make the majority of the home accessible to a wheelchair user, with a lift and sufficiently wide corridors and doorways. Adaptations to bathrooms have been implemented where needed. The only deficit is the accessibility to and in the laundry room with the door opening outwards and a washing machine with limited space for service users to use. Currently none of the residents require wheel chair access. The home appears to be maintained well and the facilities Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 19 kept in good order with repairs and routine maintenance carried out. The only area that appears to need some improvement is the garden to the rear of the property, as this did not look attractive and inviting for service users to use. Through discussion with staff it was established that they had lost the volunteers who maintained the garden facilities. Staff have been provided with facilities for sleeping- in duties with a separate bathroom that does not effect the facilities available to service users. Throughout the home the residents and staff keep the home clean and hygienic and the laundry area is located away from food preparation areas. Osborne House DS0000011278.V344718.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): 34 and 35. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There was insufficient evidence available to assess that the home protects service users by its recruitment practices or the training provided to staff. EVIDENCE: The records for the recruitment, employment, and training of staff were not available for inspection purposes. The staff spoken to during the inspection visit were not able to provide any further information of how the recruitment process is carried out except that residents were given the opportunity to take part in the interview meetings. This was confirmed by one of the residents who also stated that he enjoyed being part of the process. Staff did state that they were given opportunities for training and personal development. However, the records for the planned training programme and what staff had obtained since the last inspection process were not available. Therefore it was difficult to assess that staff had been suitably equipped to provide support to meet the specific needs of the people living in the home. Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 21 The manager did provide information prior to the inspection visit that over 50 of the staff employed had obtained and NVQ 2 or above. Staff did confirm that they had regular formal supervision meetings although they had not been provided with documentary evidence of these that would aid them to plan and review their own practices and training needs. The duty rota was reviewed to assess the staffing levels in place to support the service users and the administration needs of the service. The deputy manager has had the responsibility for the development of this until recently and staff confirmed that the requirement made during the last inspection process to provide designated specific time for the management of the home, had been carried out. This was reflected by the manager being not included in the shift patterns and having core times to perform her duties. There is an approximate deficit of one and half full time equivalent staff to meet the needs of the service that is covered by bank and some agency staff. This includes the deputy manager’s position as this staff member has reduced her responsibilities and hours to attend further training. Osborne House DS0000011278.V344718.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 and 42. Quality in this outcome area is poor. These judgements have been made using available evidence including a visit to this service. The home is not managed in the interests of the residents living there. Residents, staff, and visitors are not fully protected by the working practices for health and safety. EVIDENCE: The manager was not available during the inspection process but had provided some information prior to this in the AQAA. Information in regard to training and development that the manager has undertaken to maintain her role since the last inspection was also not available. Residents are consulted about their opinion of the service through service users meetings that are recorded by staff. Staff could not provide information that a more formal process had been carried out. The manager stated in the AQAA that the provider organisation carried out regular monthly audit visits Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 23 (Regulation 26) that includes consulting with residents and reviewing records. There was some documentary evidence available to support this in the home. What was apparent was that staff throughout their interaction with the residents and the key worker meetings there was a continuous consultation process where service users were invited to comment, give opinions and make changes to planned activities. However, documentary evidence that these meetings were occurring for all the residents could not be found. It was quite clear that staff had not been provided in the home with all the necessary policies, procedures, and information in order to meet their responsibilities and the recognised professional standards. There were some documents in regard to employment legislation and responsibilities but none to support care practices and key health and safety guidance relevant to a care setting. What was also evident was the requirements made previously to improve the quality of the care planning records had not been implemented and they remain not up to date, disorganised and do not support that staff are given sufficient instruction to provide a consistent standard of care. The information and records for safe working practices were reviewed to ensure that both service users and staff are protected by the regular safety checks carried out and also the training provided to staff and the environment is fit and safe for purpose. There is a programme of safety checks carried out with records to support that any repair or replacement are carried out. These were with reference to gas and electrical supply and equipment. There were also records regarding fire safety equipment, fire drills, and emergency lighting. What was evident there is a formal process for health and safety checks put in place by the provider that should be carried out, according to the documentary records seen, every month. However, the last recorded process was carried out in April 07 and has not been completed since then. The records for the safe management of the chemicals or substances that should be kept in accordance to the COSHH regulations were reviewed to see the measures they have in place to protect service users and staff. The records seen were not up to date, did not reflect the items used in the home or provide staff with consistent information. Some of the data sheets were implemented in 1995. Osborne House DS0000011278.V344718.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 X 2 1 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 2 1 X 2 X X 2 X Osborne House DS0000011278.V344718.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 YA2 Regulation 14 Requirement That the home ensure that the needs of the service user are assessed and re- assessed regularly to identify that they can meet the needs of the individual taking into consideration the needs of the other service users living in the home. Review and update all service users care plans This was a previous requirement to be met by 31/12/06. Review and update necessary risk assessments This was a previous requirement to be met by 31/12/06. Update health and welfare records to promote service users choice and preference. This was a previous requirement to be met by 31/12/06. This should be that the care planning records give information of how the staff are DS0000011278.V344718.R01.S.doc Timescale for action 31/01/08 2. YA6 15, 17(3) Sch 3 31/01/08 3. YA9 13(4) 31/01/08 4. YA18 12 (1a) (3) 31/01/08 Osborne House Version 5.2 Page 26 5. YA19 12 (1a) (3) 6. YA34 17 7. YA39 24 8. YA41 17 9. YA42 12.1 to provide personal care support to the individual. Update health and welfare records to promote service users choice and preference. This was a previous requirement to be met by 31/12/06. This should be that the home ensures that it has the necessary systems in place to identify and meet the health care needs of the service users. That the records for the recruitment, employment and training are at all times available in the care home for inspection by a person authorised by the commission Develop formal Quality Assurance system. This was a previous requirement to be met by 31/03/07. That a formal process for consultation with service users and informing them of the outcomes is implemented. Review, organise and update records in the home. This was a previous requirement to be met by 31/12/06. The home should provide staff with the necessary guidance and information through their policies and procedures to promote and make proper provision for the health and welfare of service users. 31/01/08 31/01/08 31/03/08 31/01/08 31/01/08 Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard YA7 YA17 YA20 YA21 YA22 YA22 YA23 YA24 Good Practice Recommendations That they improve how they include the information about service users choices and decision making in the care planning records. That they improve how they record the individuals nutrition needs and the meals and menu planning to meet them. That they review how they record and monitor the nonprescription medications and remedies. That they review how they seek and record service users choices in regard to ageing, illness and how they wish to be cared for at their end of their life. Ensure all complaints dealt with are detailed in the homes complaints log. That they make sure that the complaints process is known or available to relatives and visitors. That home keeps a copy of the local interagency protocols for safeguarding adults for staff to refer to. That they review the external garden areas to improve the facilities and communal spaces for service users to use. Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Osborne House DS0000011278.V344718.R01.S.doc Version 5.2 Page 29 - 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. 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