Inspection on 07/12/04 for Osborne House

Care Homes For Adults (18 ­ 65)Oscars Hotel (Osborne House)65 Vansittart Road Windsor Berkshire SL4 5BNUnannounced Inspection7th December 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 27/5/04 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 37th December 2004 10:00 am Susan BurtonID Code084774Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMeike Westrate, Manager and Mary Montgomery, Acting ManagerOscars 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. The organisation managed to find temporary accommodation nearby in Windsor that 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 unannounced inspection on Tuesday 7th December 2004 with one inspector. Requirements made from the last inspection were followed up, particularly recruitment as there had been concerns at the last inspection in regard to new staff not having CRB checks in place, therefore it was very worrying to see that the organisation had just recruited through its human resource department a new support worker with no POVA check or appropriate CRB being in place. The organisation was issued an immediate requirement to address this major shortfall, which puts the service users in the home at potential risk. Choice of Home (standards 1- 5) 3 standards were inspected all were met. The home has a Statement of Purpose and Service User Guide, which now meet the standard and required regulation and will be amended as and when the refurbishment is complete. There have been no admissions for some considerable time and none are predicted for the near future. The staff team were aware of the individuals needs both mentally and physically and care plans acknowledged the actions and support needed to be given by staff. Individual needs and choices (standards 6 - 10) 5 standards were inspected all were met. The service user case tracked had signed his care plan to evidence his involvement and agreement with the document. Each service user has an individual arrangement with their finances and staff were seen appropriately assisting one individual with the management of his money while still allowing him to spend on items he had chosen to purchase. Service users meetings take place on a regular basis and are often chaired by the homes advocate. The care plans of a service user evidenced appropriate risk assessments, which identified risk to him personally. The homes manager was able to make the confidentiality policy available for the inspection. Lifestyles (standards 11- 17) 7 standards were inspected all were met. The service users in the home are a mobile and active group who use a wide range of local resources. The service user case tracked has a programme of attending a local day centre 3 days a week and also attends a drama group of which he is a very enthusiastic member. The temporary accommodation allows the service users to access a number of leisure and Oscars Hotel (Osborne House) Page 6 activity pursuits, local shops are close by and in easy walking distance. One individual enjoys purchasing newspapers and magazines from a local shop on a daily basis. The manager advised the inspector that Advance Housing now has a sum of money in reserve for holidays for service users. Relatives had written and spoken to the inspector on previous occasion expressing their support for the efforts of the staff. The home has developed a file, which details each individual service users routines each day. There is no prescribed menu in the home or set meal times, service users have autonomy and freedom to choose what and when they eat and who with. Personal and healthcare support (standards 18 - 21) 1 standard was inspected and was met. One individual has been able to choose his own clothes from a website that supplies clothing suited to his needs. Concerns, complaints and protection (standards 22 - 23) 2 standards were inspected, 1 was met and 1 had a major shortfall. A service user in the home had made a complaint about another individual in the home to which staff had responded sensitively and appropriately. The poor recruitment practises used by the organisation was seen to have put service users at some risk. The homes own policy on POVA checks was seen but unfortunately had not been followed by the organisation. See standard 34. Environment and Recruitment (standards 24 - 30) No standards were inspection on this occasion. Staffing (standards 31- 36) 3 standards were inspected, 2 were met and 1 had a major shortfall Since the last inspection the organisation has allocated the home 2 management days but due to staffing shortages this has not been available. A previous requirement that staff were to commence employment only following the completion of a satisfactory CRB check was found to have not been followed or actioned. There was no evidence that a recently recruited support worker has been POVA checked, the organisation had used her CRB check from a previous employer that was not of a comparable nature and had used this despite the recent guidelines stating that CRB checks were no longer portable. No other information on the individual was available in the home as a central human resource office at the organisations head office carries out all the recruitment checks. This is a major shortfall of a serious nature. Conduct and management of the home (standards 37 ­ 43)_ 6 standards were inspected, 3 were met 2 had a minor shortfall and 1 had a major shortfall. The homes Registered Manager had completed her NVQ 4 but did not have verification available on inspection. Service users are able to voice their views and concerns through one-to-one sessions with their key workers and at resident meetings. The manager advised the inspector new and updated policies were being sent through on a regular basis from the organisations new quality assurance department. Recruitment records required by regulation for the protection of service users were not in place. A previous recommendation that Legionella testing be carried out had not been actioned. The organisation had provided the manager with a financial forecast, which gave projected Oscars Hotel (Osborne House) Page 7 costing for the home for the year 2005/06.Oscars Hotel (Osborne House)Page 8 Requirements from last Inspection visit fully actioned? If No please see overleafNOSTATUTORY 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 actionAction 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 StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Oscars Hotel (Osborne House)Page 9 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 19 Schedule 2 17 Schedule 3 19 Schedule 2 2 17 (2) (3b) Schedule 4 YA34 Staff are to commence employment only following the completion of a satisfactory CRB check. Volunteers are to have CRB checks. Previous requirement Records of information required by regulation and schedule are to be available in the home and available for inspection. Previous requirement1YA34Immediate10/1/05Oscars Hotel (Osborne House)Page 10 RECOMMENDATIONS 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 * YA34 Evidence of Legionella testing is to be available. Previous recommendation.1* 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 · 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 Oscars Hotel (Osborne House) YES YES NO YES YES NO NO NO YES NO YES YES YES YES NO NO NO NO NO YES Page 11 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) 1 X X NO NO YES YES X X 7/12/04 10.00 3.5The 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 (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)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 12 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 3 Key findings/Evidence Standard met? The home has a Statement of Purpose and Service User Guide, which now meet the standard and required regulation and will be amended as and when the refurbishment is complete.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. 3 Key findings/Evidence Standard met? There have been no admissions for some considerable time and none are predicted for the near future. The manager advised the inspector that there is an admissions procedure in place.Oscars Hotel (Osborne House)Page 13 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. 3 Key findings/Evidence Standard met? From the records seen and the observations made it is supportive of this standard as met. The staff team were aware of the individuals needs both mentally and physically and care plans acknowledged the actions and support needed to be given by staff. The home is hoping an ex-member of staff will also become an advocate to support the efforts of the homes existing befriender advocate. 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? Not inspected on this occasion.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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Oscars Hotel (Osborne House)Page 14 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. 3 Key findings/Evidence Standard met? There was one service user in the home during the inspection who was enjoying a free day and a lie in. The individuals communication needs were documented and understood by the individuals key worker, who was seen to have a good rapport with him. The service user has signed his care plan to evidence his involvement and agreement with the document. Appropriate risk assessments where seen on file.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. 3 Key findings/Evidence Standard met? Staff were seen assisting and supporting a service user with choices and decisions. Assistance was given with forthcoming travel arrangements to enable the individual to fly to Scotland to visit his family. Each service user has an individual arrangement with their finances and staff were seeing appropriately assisting one individual with the management of his money while still allowing him to spend on items he had chosen to purchase.Oscars Hotel (Osborne House)Page 15 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. 3 Key findings/Evidence Standard met? Service users meetings take place on a regular basis and are often chaired by the homes advocate. Minutes of the last meeting where available and evidence discussion with the service users on issues such as confidentiality and access to their personal records, the forthcoming Christmas events and a staff members leaving party. Service users are invited to attend the interviews of new staff.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. 3 Key findings/Evidence Standard met? The care plans of a service user evidenced appropriate risk assessments, which identified risk to him personally. Action taken to minimise those risks was appropriate, professional advice and guidance had been sought and had enabled a safe resolution to the risk.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. 3 Key findings/Evidence Standard met? The homes manager was able to make the confidentiality policy available for the inspection and service users had been involved in a discussion recently about access to their records. All staff had signed to evidence they had read the policy.Oscars Hotel (Osborne House)Page 16 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. 3 Key findings/Evidence Standard met? The service users in the home are a mobile and active group who use a wide range of local resources. None of the group had expressed a wish to attend church when asked.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. 3 Key findings/Evidence Standard met? The service user case tracked has a programme of attending a local day centre 3 days a week and is learning computer skills following the donation by a relative of two computers to the home. He also attends a drama group of which he is a very enthusiastic member.Oscars Hotel (Osborne House)Page 17 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. 3 Key findings/Evidence Standard met? The temporary accommodation allows the service users to access a number of leisure and activity pursuits, local shops are close by and in easy walking distance. One individual enjoys purchasing newspapers and magazines from a local shop on a daily basis. He has a building society account which the staff help him mange. The individual recently took part in a Mencap fundraising event and was able to donate a sum of money to the organisation, which had written to him personally thanking him for his support. Staff had recently discussed voting procedures with the service users but only one person expressed a wish to vote. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? The manager advised the inspector that Advance Housing now has a sum of money in reserve for holidays for service users. The organisation had agreed to offer a weekend break to service users when the refurbishment of Osborne house is complete in recognition of the disruption they have had to deal with.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). 3 Key findings/Evidence Standard met? Many of the service users in the home have good supportive family links. Relatives had written and spoken to the inspector on previous occasion expressing their support for the efforts of the staff. Relative had donated two computers and two bikes to the home for the enjoyment of the service users. One individual found the new computer a great bonus and enjoyed playing card games on it. The service user spoken to shares a bedroom with another individual in the home and was happy to express his satisfaction with the arrangement.Oscars Hotel (Osborne House)Page 18 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). 3 Key findings/Evidence Standard met? The home has developed a file, which details each individual service users routines each day, and whether any there are any issues staff need to be aware of such as transport arrangements. Service users post is kept secure and given out intact with support from staff. Service users are able to come and go as much as they are able with advice and help from staff if needed. Housework routines are minimal and appropriate to each service users ability. 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. 3 Key findings/Evidence Standard met? Service users in the home have individual shopping days with staff where they are able within a given budget able to choose a range of suitable meals that they personally enjoy. Service users make their minds up at the time of the meal what they will have and each individual has allocated freezer space for frozen items. There is no prescribed menu in the home or set meal times, service users have autonomy and freedom to choose what and when they eat and who with.Oscars Hotel (Osborne House)Page 19 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. 3 Key findings/Evidence Standard met? One individual following an O.T assessment is not safe to use the bath provided in the temporary accommodation so uses a shower instead. A routine has been established and now the individual is able to shower himself with minimal support from the staff. The individual has been able to choose his own clothes from a website that supplies clothing suited to his needs and with staff support enjoys visiting charity shops to find other items. 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 20 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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.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 21 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 1 X 1 X X X 100 3 Key findings/Evidence Standard met? A service user in the home had made a complaint about another individual in the home to which staff had responded sensitively and appropriately.Oscars Hotel (Osborne House)Page 22 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 YESX1 Key findings/Evidence Standard met? The poor recruitment practises used by the organisation was seen to have put service users at some risk. The homes own policy on POVA checks was seen but unfortunately had not been followed by the organisation. See standard 34. Each member of staff was given a booklet about the organisations whistle blowing policy on induction. A psychiatrist will visit the home every 3months approximately and will discuss and issues with staff in regard to managing service users behavioural needs.Oscars Hotel (Osborne House)Page 23 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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Oscars Hotel (Osborne House)Page 24 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 Key findings/Evidence Not inspected on this occasion. NO YES NO X X X X Standard met? 0 X XX X X XOscars Hotel (Osborne House)Page 25 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. Key findings/Evidence Not inspected on this occasion. Standard met? 0Standard 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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Oscars Hotel (Osborne House)Page 26 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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Oscars Hotel (Osborne House)Page 27 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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.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. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Oscars Hotel (Osborne House)Page 28 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 X 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 X X X X Nursing X X XXX3 Key findings/Evidence Standard met? Since the last inspection the organisation has allocated the home 2 management days but due to staffing shortages this has not been available. The Deputy had left the previous week and the manager was leaving at the end of the week, neither had left other than for personal reasons. A temporary acting manager was having an induction during the day of inspection and it was hoped with the recently recruited new staff that she would be able to use the management time allocated.Oscars Hotel (Osborne House)Page 29 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 previous requirement that staff were to commence employment only following the completion of a satisfactory CRB check was found to have not been followed or actioned. There was no evidence that a recently recruited support worker has been POVA checked, the organisation had used her CRB check from a previous employer that was not of a comparable nature and had used this despite the recent guidelines stating that CRB checks were no longer portable. No other information on the individual was available in the home as a central human resource office at the organisations head office carries out all the recruitment checks. This is a major shortfall of a serious nature; ineffective recruitment procedures that do not follow legal requirements place the service users at potentially serious risk. An immediate requirement was issued and the organisation advised by telephone of the concern. This standard has a major shortfall for the third time and enforcement action will now be considered.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 manager advised the inspector that although no one in the home was following the Learning Disability Award framework but equivalent training was being provided. This will be followed up at future inspections.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? Not inspected on this occasion.0Oscars Hotel (Osborne House)Page 30 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]. X2 Key findings/Evidence Standard met? The homes Registered Manager had completed her NVQ 4 but did not have verification available on inspection. The manager advised the inspector previously by phone that she would be leaving the home at the end of the week. The homes service manager was reminded that the organisation is required to advise CSCI of the management arrangements once she had left.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not inspected on this occasion.Oscars Hotel (Osborne House)Page 31 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? Service users are able to voice their views and concerns through one-to-one sessions with their key workers and at resident meetings. The service users in the home are able to communicate their concerns directly to the manager or any of the staff. The organisation also has an annual survey, which seeks feedback also.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). 3 Key findings/Evidence Standard met? A previous recommendation had been made that the homes policies and procedures met standard 40, appendix 2. The manager advised the inspector new and updated policies were being sent through on a regular basis from the organisations new quality assurance department. This will be followed up in more detail at future inspections.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. 1 Key findings/Evidence Standard met ? This standard is unmet due to the failure of the home to implement thorough and effective recruitment methods, which have been required by regulation at two previous inspections, and fails to protect the service users in the home.Oscars Hotel (Osborne House)Page 32 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. 2 Key findings/Evidence Standard met? A previous recommendation that Legionella testing be carried out had not been actioned.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. 3 Key findings/Evidence Standard met ? The organisation had provided the manager with a financial forecast, which gave projected costing for the home for the year 2005/06. This is complicated by the refurbishments programme being carried out at Osborne Hse and will be reviewed at future inspections.Oscars Hotel (Osborne House)Page 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateSue BurtonSignature Signature Signature07/12/04Oscars Hotel (Osborne House)Page 34 Public reports It should be noted that all CSCI inspection reports are public documents.Oscars Hotel (Osborne House)Page 35 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 7 December 2004 of Oscars/Osborne House and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Oscars Hotel (Osborne House) Page 36 Amendments to the report were necessaryNOComments 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 accurateYESNOYESNote: 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 planNOYESNOOther: enter details here Oscars Hotel (Osborne House)Page 37 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 38 Oscars Hotel (Osborne House) / 7th December 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000011278.V200138.R01© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!