Inspection on 17/11/06 for Oxbridge House

This inspection was carried out on 17th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 23 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oxbridge House 17/06/08

Oxbridge House 20/06/07

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Oxbridge House Oxbridge Lane Stockton-on-Tees TS18 4JB Lead Inspector Joanna D White Key Unannounced Inspection 17th November 2006 10:25 Oxbridge House DS0000066802.V319960.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 Oxbridge House DS0000066802.V319960.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. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oxbridge House Address Oxbridge Lane Stockton-on-Tees TS18 4JB 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) 01642 633552 01642 633551 Milewood Healthcare Limited Ms Ada Mary Ali Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection FIRST INSPECTION Brief Description of the Service: Oxbridge House is a large detached property in a quiet residential area of Stockton. The property was previously a privately owned hotel. Accommodation for nine service users is provided on three floors. Milewood Healthcare Limited has carried out extensive re-furbishment including the provision of en suite facilities to each bedroom all of which meet the spatial requirements of the National Minimum Standards. In line with Milewoods policy to encourage service users to exercise choice and to make decisions about issues affecting their lives bedrooms have been left undecorated so that each prospective service user can choose the décor and furnishings for their own room. Communal facilities comprise a dining room and sitting room. Externally there is a large garden to the front of the property and a small yard to the rear. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key unannounced inspection and was carried out by two inspectors across four different inspection days. The first day was unannounced with the other three days planned with the home, a total of thirty inspection hours. All of the key standards were examined during the inspection. During the visits the inspectors spoke to the two residents, who had been residing at the home for less than a month, and staff to find out what their views were about living and working at Oxbridge House. Time was also spent watching the interaction between the staff and the residents. Two of the resident’s files, all of the staff files, including recruitment and selection, and the homes medication records, health and safety records, and policies and procedures, were examined during the inspection. A tour of the home also took place. The homes handling of resident’s money was also examined. The Inspectors felt warmly welcomed to the home by the resident’s, staff and the manager. There was much discussion throughout the inspection with the manager, the responsible individual, and the operations manager. In addition brief discussions took place with the Training Manager and maintenance staff. A pre-inspection Questionnaire was provided, which had been completed by the manager. The manager informed the inspectors that the charges for residents’ care and accommodation were £1389.81 per week. £13.13 per hour was charged for any resident who required additional one to one support. The pre inspection questionnaire confirmed extra charges were made for toiletries, clothes etc. What the service does well: The residents were observed to be relaxed in the presence of staff and able to talk to them about how they were feeling. One resident said, “ It is great living in Oxbridge. I really like it here. I have only been here for a short time. My room is nice,” another said, “l am settled here. The staff are great and really help me. They listen to what I have to say” The residents are supported to maintain contact with their relatives and families who are also very welcome and encouraged to visit the home. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 6 The manager and staff ensure the residents are consulted about and involved in a variety of activities. Staff said, “ We really like working here. It is just like a family. It is excellent. The manager is really supportive” What has improved since the last inspection? What they could do better: It is of concern that this home has been operational without appropriate resources and systems being in place to ensure that the needs of the residents are actively promoted and met. As a result of this inspection a large number of requirements and recommendations have been made. The home should develop a comprehensive Statement of Purpose, which clearly specifies the resident group for whom they are providing care. A comprehensive assessment of the resident’s aspirations and their needs should be completed prior to the residents’ admission including maintaining written records of all contacts with all of the agencies involved. The manager should carefully consider the needs assessment for each individual prospective person and the capacity of the home to meet their needs before agreeing admission to the home. Prospective residents should be given the opportunity to spend time in the home before making a decision to move to there. The manager must develop and agree with each resident an individual plan of care which details how their health and welfare needs are going to be met Care plans should include a comprehensive risk assessment, which takes into account the residents specialist needs, balanced with their aspirations for independence, choice and normal living. Where there are limitations on choice or facilities, and it is in the resident’s best interest the resident must fully understand and agree the limitations. Any limitations should be fully documented and reviewed on a regular basis to ensure their ongoing relevance. Staff should help the residents to take responsible risks by making decisions which are informed by good information which is within the context of the residents individual plan and the homes risk assessment and risk management strategies. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 7 An assessment of the resident’s healthcare needs should be completed. The home must have procedures in place to make sure that they are met. The manager and staff should encourage and support residents 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. Suitable arrangements should be made for the recording, handling, safekeeping, safe administration and disposal of all medicines including controlled drugs received into the care home. The training for all care staff should be accredited and include basic knowledge of how medicines are used and how to recognise and deal with problems in use and the principles behind all aspects of the home’s policy on medicines handling and records. The complaints procedure should be reviewed and updated to include local information and the fact the residents can make a complaint to the commissioning authority The protection of vulnerable adults procedure should be reviewed and updated to contain the local contact details. The fire escape, which has flaking paint and is rusting in places, should be painted. One immediate requirement (immediate action to be taken by the manager to address concerns) was issued in respect of staff training and development. Suitably qualified, competent, and experienced persons should be working in the care home at all times. The staff training and development programme should meet meets Sector Skills Council workforce training targets. The recruitment and selection procedures should be updated and robust. References should be appropriate and present on staff files. All application forms should be appropriately completed. CRB checks should be completed before staff are employed and records should demonstrate that the staff are being appropriately supervised. References must be appropriate and present on staff files. All staff files must include all of the information as stated in Schedules 2 & 4 of The Care Homes Regulations 2001. Documentary evidence should be provided in staff records of the exploration of any gaps in employment for staff prior to the commencement of employment. The manager should continue to implement the homes action plan and improve and develop systems that monitor practice and compliance with the homes plans, policies and procedures Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 8 The manager should measure success in achieving the aims, objectives and statement of purpose of the home by continuing to develop and fully implement effective quality assurance and quality monitoring systems. The fire evacuation policy and alarm on the fire door should meet the requirements of the fire authority. 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. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 9 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 Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 and 4 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not provide a Statement of Purpose that is specific to the individual home, and the resident group they care for. A comprehensive assessment of the resident’s aspirations and their complex needs is not completed and recorded prior to their admission to the home. The capacity of the home to meet the residents assessed needs is not demonstrated. Not all residents have had an opportunity to visit and to “test drive” the home. EVIDENCE: The statement of purpose was examined and was revealed to contain contradictory information. One section stated the home “ Provide accommodation for Learning disabled adults with challenging behaviour” whilst the admission criteria stated “ Provide 24 hour care for adult men and women with mild to moderate learning disabilities.” The matter was discussed with the operations manager who agreed to review and update the information as a matter of urgency. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 11 A copy of the Resident’s charter was shared with the inspectors and provided 29 areas of very clear and detailed information for new residents about, privacy, independence, choice, dignity, the first step, moving into the home, settling in, medical care aids and facilities, visitors, smoking, telephone calls, etc. An examination of two residents files evidenced detailed and comprehensive assessment information had been obtained by the manager prior to their admission, which outlined the needs of the residents as documented in the placing authorities Care Manager’s Care Management Assessments and Care Plans. Whilst the manager confirmed that there had been discussion with significant others such as care managers, support workers, deputy services manager and key worker, psychiatrist and GP and the perspective resident themselves there was no documentary evidence available on the files. In addition due to the lack of clarity regarding whom the home was providing accommodation for it was unclear as to what criteria had been used to determine whether or not the home would be able to meet the needs of the perspective residents. The manager also said that for a variety of reasons not all residents had had an opportunity to visit the home prior to admission. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 12 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 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents assessed, changing needs and personal goals are not reflected in their care plans. Although residents make decisions about their lives and staff provide support when necessary appropriate risk assessments are not in place.. The residents live individual lifestyles and are supported to make appropriate decisions, which are not reflected in their care plans. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 13 EVIDENCE: At the time of the inspection the plans of care present on the two residents records, which were examined, contained limited information. The operations manager and manager said the documentation was in the process of being reviewed and updated .A copy of the new documentation entitled “ My plan, my choice, my prospect, my lifestyle plan” was shared with the inspectors and was observed to be in a user-friendly format and reflected more person centred planning. The operations manager confirmed staff training to use the documentation would take place before it became fully operational week commencing 4th December 2006. Although risk assessments, were in place one resident’s file which was examined indicated that these had been completed whilst he/she had been living in another home and there was no evidence that they had, where necessary, been reviewed or updated since the admission of the resident to Oxbridge House. The manager stated that all risk assessments were in the process of being monitored, reviewed and updated in liaison with the residents and other professionals involved. The inspectors were also concerned that in some areas e.g. residents’ smoking, proper assessments of risk and risk management strategies had not been put in place. These concerns were also shared with the operations manager and the manager and it was pointed out that the assessments of risk and risk management strategies should be developed alongside the residents care plan and appropriate agreements drawn up between the resident and the home. Activities to promote the residents independence such as, washing their clothes, making a hot drink or snack, cleaning their room, ironing their clothes and helping in the kitchen also required risk assessments which were not present on the files. The homes statement of purpose also said “ as this is your home we believe that you should have your say in its future plans and in resolving issues that may arise from time to time.” The minutes of residents meetings, which had been signed by the residents and staff involved, confirmed that meetings took place on a regular basis. Topics discussed included “ would like to run an allotment” “ service users are happy with their rooms” “ would like some gardening tools” “ happy with house facilities” Proposed activities included “ visiting York, Beamish, and going on holidays” Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 14 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. Staff enable as far as possible the opportunities for the residents to maintain and develop their social, emotional, communication and independent living skills whilst respecting their rights and responsibilities in their daily lives. Staff support the residents to become part of and participate in the local community in accordance with their assessed needs and Individual Plans. Residents have opportunities to develop appropriate personal family and sexual relationships. The residents were very satisfied with the meals provided Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 15 EVIDENCE: The homes Statement of Purpose showed it was their intention to provide in house activities such as “disco nights, music sessions, crafts, cookery, video/ DVD nights, games nights, beauty sessions, bingo, snooker, and gardening and if the service users have new ideas or would like to do something different the staff will try their best to accommodate” It continued by stating“ Staff will also discuss with you which of the home activities that you would like to be involved in “Reference was also made to religion and culture “ encourage individuals to attend religious or spiritual services or receive religious instruction on the premises in response to their needs wishes and understanding , ….And to enable them to take reasonable risks in reaching their full potential” Additional activities would include board games taking photographs horse riding, bowling, swimming, dancing, gardening, art and craft. The residents would also be encouraged to attend the local college. Staff said “ We took a resident to Yarm and have just got back. It is good for the residents to go out. We are planning other trips especially now it is getting near to Christmas” One resident said,” I like playing pool with the staff” Another resident said, “ I like to go shopping” The residents also told the inspectors that they could choose when to be alone or in company and when not to join in an activity. On one day of the inspection residents were observed listening to music in their room. On another day a resident was observed chatting to the staff. One resident told the inspector “ The food here is great I had liver and potatoes the other night and I can make myself a drink and have snacks including crisps. Tonight we are having chicken I can go to the shops with the staff and buy the food I like”. Staff confirmed the food was very good and one member of staff said she had “made soup for lunch and there was a plentiful supply of fresh food and vegetables. The residents also had variety and choices were also available.” The manager provided weekly menus and said, “the residents were receiving a balanced and nutritious diet” One resident had regular weekly contact with his/her mother who had arranged to visit the home. Another resident was looking forward to his/her sister visiting. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 16 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,and 20. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff meets Resident’s personal needs in a sensitive and flexible manner. In accordance with the wishes of the individual resident staff do not meet the resident’s healthcare needs. The homes medication policies and procedures are not as robust as required and need further review and development to ensure safe and effective systems are in place. EVIDENCE: Staff who were spoken to confirmed that they respected the privacy, dignity, independence, choice, rights and fulfilment of the residents. The home’s statement of purpose said, “ We believe strongly that you have individual needs and your right to decide what happens to you is of paramount importance to us” Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 17 One resident’s file, which was examined, confirmed, “Times for going to bed were flexible” The staff said they were getting to know the residents and knew how important it was for their emotional needs to be met. A resident said “ “ I have been to see the doctor with a member of staff who was there to help me.” Residents’ records confirmed that they had contact with Care Manager, Outreach Team, Psychologist, Consultant Psychiatrist, GP, Community Psychiatric Nurse, Optician, Chiropodist, Dentist, Nurse and Dietician. Conversely one residents record revealed that he /she had a number of health needs. However the help and support that the manager and staff said was being offered was not recorded in the residents care plan. The manager stated that none of the residents administered their own medication. However there was no evidence to confirm whether or not the residents had been consulted as to whether or not they wished to administer their own medication. The homes medication policies and procedures were examined and did not provide sufficient detail in terms of receipt, storage, handling, administration, and disposal of medication. The manager said that no current residents were prescribed controlled drugs and confirmed that there was no system in place to record the receipt, administration and disposal of controlled drugs. She confirmed that the matter would be addressed as a matter of urgency. The medication administration records for two residents were examined and evidence of a second member of staff witnessing all hand written annotations charts was present. Weekly auditing by the manager was also present. However the medication profile for one resident, which was present on their file needed to be reviewed and updated. The operations manager confirmed that the homes medication policies and procedures had been reviewed and new recording tools and monitoring /auditing forms were in the process of being introduced copies of which were shared with the inspectors. Discussions with the staff who were on duty revealed that they had not undertaken any medication training. However they added that they had no responsibility for the administration of medication. The operations manager confirmed places for staff had been secured on the twelve-week safe handling of medication course. He added that new systems were being introduced to monitor the competency of staff in administering medication on an ongoing basis within the home following the staff’s completion of this course. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 18 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. The staff and manager listen to the residents and take their views seriously. The written procedures, which are in place, lack clarity in promoting the welfare of the residents. EVIDENCE: A copy of the information given to residents was examined which provided comprehensive and detailed guidance including the stages of and timescales for the process. The residents knew how and to whom to complain within the home. The complaints process was in an accessible format but it did not specify that residents could make a complaint to the commissioning authority and did not contain any local information. Staff confirmed, “ We would know what to do if a resident wanted to make a complaint” The complaints record was examined and revealed that one complaint had been dealt with satisfactorily within 28 days. A compliment had also been received by the home “Thank you so much –this message comes just to say Thank you very much” Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 19 The home had a photo copy of the No Secrets Protection of Vulnerable Adults Teeswide Guidance but their actual procedure needed to be updated, as it did not contain details of local arrangements such as contact people and telephone numbers in the event that an allegation was made. Two members of staff who spoke to the inspectors confirmed they had attended the appropriate training and gave clear examples of how they would respond in particular situations. Staff files, which were audited, verified the staff had completed the relevant training. There had been two vulnerable adult referrals, which had been dealt with appropriately. The expenditure records for one resident were examined. Signatures of the staff member and the resident were recorded and all receipts were available. An audit trail by the manager was also present. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 20 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 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents are provided with a homely, and predominately well-maintained environment to suit their needs and lifestyles, which is clean and hygienic. EVIDENCE: The home provided the residents with a comfortable and homely environment, which was airy and clean. The manager informed the inspectors that the downstairs room at the front of the property was in the process of being converted into a games room for the residents. All of the residents were provided with a single room, which had en suite facilities. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 21 Two of the resident’s bedrooms were seen by the inspectors and contained new bedroom furniture, carpets and curtains. Personal items such as televisions, cd players and cd’s, videos, photographs, and a computer were also present. One resident said “ I really like my room it is great I have plenty of room I like spending time in my room. I chose the carpets and the curtains and the colour for the walls.” Another resident said, “ I like my carpet and I can watch my television and listen to my music. The room is really comfortable. It is very quiet here.” The fire escape was observed to have flaking paint and was rusting in places. The operations manager confirmed he would make the necessary arrangements for it to be painted. A member of the maintenance staff spoke to the inspector and said he was employed to undertake “ a bit of plumbing and electrical work” In addition he maintained the garden, completed decorating jobs, and undertook repairs. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. There have been recent difficulties in the home concerning the provision at all times of suitably qualified, competent, and experienced staff to ensure the needs of the residents are met. Residents are not supported and protected by the homes recruitment policy and practice. EVIDENCE: At the time of the inspection the manager confirmed a number of trained staff had left Oxbridge House. An examination of staff training and recruitment records revealed the home was not ensuring that at all times suitably qualified, competent, and experienced persons were working at the care home, and as a result the registered provider was instructed to take immediate action to address these issues. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 23 Since the inspection commenced improvements were noticed following an examination of the staff rota and discussion with the manager, the training manager and the operations manager. Discussion with staff also confirmed that an intensive training programme was taking place. A further examination of staff records revealed that all mandatory training had been provided. The manager stated that only one of the care staff had achieved NVQ level 2. The operations manager and the manager confirmed that all of the remaining staff had enrolled to start the relevant training. The manager also stated that all staff had been enrolled on the ‘safe handling of medication course’ with Middlesbrough College. An examination of staff files identified that the recruitment and selection procedures were not robust. One staff file, which was examined, did not have suitable references and in another file there was only one reference present. In a further file a staff member commenced employment prior to CRB and there was no recording present to demonstrate that he/she was being appropriately supervised. There were concerns regarding the CRB subsequently received and this matter is being addressed with the provider outside of this report. Another staff file, which was examined, did not contain any copies of their qualifications and in a further staff file there was no CRB, only one reference, no evidence of qualifications, no evidence of an interview, and no job description. The manager added plans were in place for the residents to become involved in the recruitment and selection processes within the home on an informal discussion basis. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 24 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): 37,39,40 and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The registered manager is appropriately qualified and experienced but there are areas, of her management, which require further development. The home is in the process of developing the quality assurance self-monitoring system to review and develop the services provided to the residents. The homes policies and procedures need to be brought up to date. The health safety and welfare of the residents are not promoted and protected. EVIDENCE: Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 25 The manager and operations manger confirmed that there were areas for improvement in the way the home was being managed. A copy of an action plan detailing all of these was shared with the inspectors. The operations manager confirmed he would be monitoring progress through supervision and regular visits to the home. Quality assurance was discussed with the manager who confirmed that this was an area, which was being developed. The manager said it was her intention to have regular formal consultation with residents and their families and that these consultations would include questions such as ‘the internal and external environment of the home, personal care, visits, communication, staff, and any other comments.’ The manager also shared with the inspector copies of questionnaires, which had been completed by previous residents which she said had been discussed with the residents about their life in Oxbridge House, but the outcomes of this survey were in the process of being collated and were not available for the inspectors. The operations manager said whilst questionnaires had been developed for residents and their families additional work was taking place to seek the views of stakeholders in the community on how the home was achieving its goals for the residents. Informal systems such as residents meetings and discussions with residents were described. The manager also confirmed residents had completed questionnaires but a final report detailing the outcomes had not been completed. The homes policies and procedures were examined and discussion with the operations manager confirmed that these were all in the process of being reviewed and updated. During the inspection the health, safety and welfare of the residents was not promoted and protected in some areas. The fire evacuation procedure also required further development. The fire escape was examined and was observed to have peeling paint and was rusting in places. Bird droppings also constituted a slipping hazard. The alarm on the fire door could not be heard in all parts of the building. The manager agreed to ensure appropriate action was taken to address these problems. Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 26 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 1 2 1 3 1 4 1 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 1 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 2 X 2 X Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO FIRST INSPECTION STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 Requirement The registered person must ensure the home develops a comprehensive Statement of Purpose, which clearly specifies the resident group for whom they are providing care. The registered person must ensure that a comprehensive assessment of the resident’s aspirations and their complex needs is completed and recorded including contacts with all other agencies involved prior to the residents admission. The registered person must ensure before agreeing admission the home carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs The registered person must ensure prospective residents are given the opportunity to spend time in the home before making a decision to move to there. The registered person must ensure the registered manager develops and agrees with each resident an individual plan of DS0000066802.V319960.R01.S.doc Timescale for action 30/12/06 2. YA2 15 30/12/06 3. YA3 12 30/12/06 4. YA4 14 30/12/06 5. YA6 15 28/01/07 Oxbridge House Version 5.2 Page 28 6. YA7 Schedule 3 7. YA9 13 (4) b 8. YA19 12 9. YA20 13(2) Schedule (3) (I) 10. YA20 13 (2) care which details how their health and welfare needs are going to be met. The registered person must ensure care plans include a comprehensive risk assessment which takes into account the residents specialist needs, balanced with their aspirations for independence, choice and normal living. Where there are limitations on choice or facilities, and it is in the resident’s best interest the resident must fully understand and agrees the limitations. Any limitations should be fully documented and reviewed on a regular basis to ensure their ongoing relevance. The registered person must ensure that the staff help the residents to take responsible risks by making decisions which are informed by good information which is within the context of the residents individual plan and the homes risk assessment and risk management strategies. The registered person must ensure there is an assessment of the resident’s healthcare needs. The home must have procedures in place to make sure that they are met. The registered person must ensure the manager and staff encourage and support residents 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. The registered person must DS0000066802.V319960.R01.S.doc 28/01/07 28/01/07 28/01/07 01/02/07 01/12/06 Page 29 Oxbridge House Version 5.2 11 YA20 18 (1)(c) 12 YA22 22 13 YA23 13 14 YA24 13 (4)(a) 23 18 (1)(a) Schedule 2 15 YA32 YA33 YA34 make arrangements for the recording, handling, safekeeping, safe administration and disposal of all medicines including controlled drugs received into the care home. The training for all care staff must be accredited and include i. Basic knowledge of how medicines are used and how to recognise and deal with problems in use; and ii. The principles behind all aspects of the home’s policy on medicines handling and records. The registered person must ensure the complaints procedure is reviewed and updated to include • Local information • Residents can make a complaint to the commissioning authority. The registered person must ensure the protection of vulnerable adults procedure is reviewed and updated to contain the local contact details. The registered person to ensure the fire escape, which has flaking paint and is rusting in places, is painted. The registered person must ensure that at all times suitably qualified competent and experienced persons are working at the care home. 01/03/07 31/01/07 31/01/07 30/12/06 17/11/06 16 YA32 18 (1)(a) Schedule 2 (4) 17 and 19 17 YA34 The registered person should 17/11/06 ensure the staff training and development programme meets Sector Skills Council workforcetraining targets. The registered person must 17/11/06 ensure that the recruitment and selection procedures are updated DS0000066802.V319960.R01.S.doc Version 5.2 Page 30 Oxbridge House 18 YA34 19 19 YA37 8 9 20 YA39 24 21 YA42 23 and are robust. References must be appropriate and present on staff files. All application forms must be appropriately completed. CRB checks must be completed before staff are employed and records must demonstrate that the staff are being appropriately supervised. References must be appropriate and present on staff files. All staff files must include all of the information as stated in Schedules 2 & 4 of The Care Homes Regulations 2001. The registered person must ensure documentary evidence is provided in staff records of the exploration of any gaps in employment for staff prior to the commencement of employment. The registered person should ensure that the manager continues to implement the homes action plan and improve and develop systems that monitor practice and compliance with the homes plans, policies and procedures The registered person must measure success in achieving the aims, objectives and statement of purpose of the home by continuing to develop and fully implement effective quality assurance and quality monitoring systems The registered person must ensure its fire evacuation policy and alarm on the fire door meet the requirements of the fire authority. 17/11/06 01/03/07 30/12/06 01/12/06 Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations The resident following assessment as able to selfadminister medication, should have a lockable space in which to store medication to which suitably trained designated care staff may have access with the resident’s permission. Controlled drugs administered by staff should be stored in a metal cupboard which complies with current regulations and guidance issued by the Royal Pharmaceutical Society of Great Britain. The Receipt, administration, and disposal of controlled drugs should be recorded in a controlled drugs register. 50 of care staff in the home should achieve NVQ Level 2 Evidence should be available to show that verbal contact has been made to verify and validate the content of at least one of the references given. All of the homes policies and procedures should be regularly updated and this should be confirmed by the date of review, which should be recorded on each document. 2. 3. 4. YA32 YA34 YA40 Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Oxbridge House DS0000066802.V319960.R01.S.doc Version 5.2 Page 33 - 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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