Inspection on 15/04/08 for Oxclose Lane Care Home

This inspection was carried out on 15th April 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oxclose Lane Care Home 15/05/07

Oxclose Lane Care Home 11/05/06

Oxclose Lane Care Home 23/02/06

Oxclose Lane Care Home 23/08/05

Oxclose Lane Care Home 09/12/04

Oxclose Lane Care Home 19/05/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Oxclose Lane Care Home 154-156 Oxclose Lane Arnold Nottingham NG5 6FF Lead Inspector Jayne Hilton Unannounced Inspection 15th April 2008 10:30 Oxclose Lane Care Home DS0000008731.V362394.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 Oxclose Lane Care Home DS0000008731.V362394.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. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oxclose Lane Care Home Address 154-156 Oxclose Lane Arnold Nottingham NG5 6FF 0115 967 0657 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) h2m057kimbley@mencap.org.uk www.mencap.org.uk Royal Mencap Society Ms Catherine Kimbley Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th May 2007 Brief Description of the Service: Oxclose Lane Care Home provides support including personal care and accommodation for seven people. It is located within close proximity to all community amenities. There are two lounge areas and a large kitchen/diner. All service users are accommodated in single bedrooms. The ground floor bathroom offers assisted bathing facilities. The ground floor is accessible to wheelchair users and three of the bedrooms are on this floor. There is no lift to the other four bedrooms. The care provider is Mencap Homes Foundation, Metropolitan Housing Association own the premises. Information about the service is provided through the service user guide and statement of purpose. A copy of the most recent inspection report from the Commission for Social Care Inspection is kept at Oxclose Lane. On 15th April 2008 the Registered Manager stated that the current weekly fee range is between £352 to £490. She also said that there are no additional charges. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for people living in the home and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 6 daytime hours and was unannounced. The manager and people who live at Oxclose lane have asked us to refer to them in this report, as ‘tenants’. The main method of inspection used was called ‘case tracking.’ This involves selecting two tenants and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Some of the people who live at this home have a very limited ability to understand and communicate. Therefore many judgements in this report are from observation and reading tenants records and documents. The tenants who were “case tracked” were not able to help by giving an opinion about the care provided, but two other tenants were spoken with. Two members of staff and the manager were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to tenants. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history including complaints and adult protection referrals, and an Annual Quality Assurance Assessment questionnaire completed by the registered manager. Four completed residents satisfaction questionnaires were also received prior to this inspection report being finalised. Four relatives were spoken with by telephone. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 7 All support plans have been updated in the last 12 months incorporating photos of tenant’s choice and Health Action Plan’s are being developed for all tenants. All plans are now current and up to date. Tenants are more aware of their content of plan and in its development. The home has implemented Mencap’s procedure for medication errors. The service has a pictorial complaints procedure now in place. All staff have received protection of vulnerable adults training and annual refreshers are planned. The team and tenants have been working together to improve the appearance internally and externally at the service. All staff has received infection control training at the induction stage of employment. Practice is reviewed by the manager in the supervision sessions, using the organisation infection control policy as guidance. Changes to tenants individual spaces have been made having received request for additional fixtures and fittings following the services redecoration. The home is now incorporating actions from inspection visits, tenants meetings, team meetings into the services continuous improvement plan. What they could do better: Two Requirements have been set in respect of this visit to the home, The manager must access referral training for safeguarding without delay. Ensure notifications are always made to CSCI as required by Regulation 37, of any events, which affect the health and well being of a tenant living at the home. Ten good practice recommendations have been made to further improve the service as follows: Introduce running records, which document the lifestyle experience of the individual, including their social and leisure activities, which should be used to Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 8 monitor and evaluate that the tenants support plan is being followed by staff and the individuals needs are being fully met. Ensure where limitations are in place such as the night monitor appropriate documentation and agreement are in place. Record keeping of individual’s dietary intake/meal choice options could be improved. Ensure risk assessments are in place for the prevention of pressure areas and how the risk is to be minimised/managed, including details of any equipment is in place. Also include nutritional screening tools within the support plan and include weight-monitoring records. These additions to the support plan format would give a comprehensive overview of tenants health needs and act as an indicator of change in health requirements. Ensure records are in place, which provide documentary evidence that the risk assessment for surface temperatures of radiators have been continually reviewed. Ensure relatives are provided with a copy of the inspection report and complaints procedures. Records for testing/probing safe food temperatures were not in place and therefore it is recommended that the manager seek advice from the Environmental Health Officer in respect of this. Ensure the electrical circuit systems in the home are safe and send a copy of the safety certificate to CSCI when completed. 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. Oxclose Lane Care Home DS0000008731.V362394.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 Oxclose Lane Care Home DS0000008731.V362394.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 excellent. This judgement has been made using available evidence including a visit to this service. Tenants and their representatives have the information needed to choose a home that will meet their needs. EVIDENCE: Significant time and effort is spent planning to make admission to the home personal and well managed. Prospective tenants and their families are treated as individuals and with dignity and respect for the life-changing decisions they need to make. There is a high value on responding to individual needs for information, reassurance and support. The home has developed a comprehensive statement of purpose and service user’s guide, which is very specific to the tenant group and considers the different styles of accommodation, support, treatment, philosophies and specialist services required to meet the needs of people who use the service. The information is in a format suitable for their and their families’ needs, using, for example, appropriate language, pictures or Braille. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 11 Staff use innovative methods to make the information they give meaningful and interesting for example, use of leaflets and photographs All new tenants receive a comprehensive needs assessment before admission. This is carried out by staff with skill and sensitivity. The service is highly efficient in obtaining a summary of any assessment undertaken through care management arrangements, and insists on receiving a copy of the care plan before admission. Individuals are supported and encouraged to be involved in the assessment process. The Registered Manager stated in the AQAA [Annual Quality Assurance Assessment] as follows: “ We do the following to ensure that race, gender identity, disability, sexual orientation, age, religion and belief are promoted and incorporated in to what we do. As a service provider organisation Mencap has a diversity policy that clearly states that people are treated fairly and no one is treated badly because of something that is different about them. We welcome the differences in people and this is why we tailor support around people’s unique needs and wishes. Our policies and processes in recruitment, training and service delivery encourage us to focus on how diversity can enhance the way we support people” There was some evidence gathered at the inspection that supported this statement such as fairly detailed support plans and staff spoken with said they promoted Equality and Diversity within their practice but they identified that further work could be developed to improve the lifestyles of current and potential future tenants. Staff demonstrated a keenness to obtain resource details to further embrace the agenda of Equality and Diversity within the home. One person’s support plan in respect of their communication needs was excellent. The plan was extremely detailed and had been developed over time by staff interpreting and understanding one word statements and non verbal communication of the individual in order to ensure the persons needs were met. The staff team are commended for this. Oxclose Lane Care Home DS0000008731.V362394.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, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Tenants are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: The service involves individuals in the planning of their care and support, which affects their lifestyle and quality of life. Staff understand the importance of tenants being supported to take control of their own lives. Individuals are encouraged to make their own decisions and choices. The service records the preferred communication style of the individual, and uses proven methods that enable the person to lead a full life that promotes independence and choice. [Communication aids such as photographs and symbols.] Support plans are person centred and are agreed with the individual. Plans are written in plain language, are easy to understand and look at all areas of the Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 13 individual’s life. They could however be improved to include more reference to equality and diversity. Staff have skills and ability to support and encourage tenants to be involved in the ongoing development of their plan. Staff make the process interesting and use a variety of ways to help individuals make a worthwhile contribution. A key worker system now allows staff to work on a one-to-one basis and contribute to the support plan for the individual. This area that requires further development, particularly as currently there is little evidence of recorded input by staff or achievement of tenants. This is because the service does not have a system of running records on a daily basis of the lifestyle and events of tenants and therefore support plans contain sparse information by which to monitor and evaluate if the tenant’s needs are being fully met. It has to be acknowledged that there was no evidence that tenants needs were not being met, but the lack of running records does mean that information may be missed and that there is no record of staff practice, support given or any interventions logged. Staff do record what they deem to be significant issues, but these may be weeks apart. Support plans are written with the individual, or their representative, and includes a range of information that is important to them, including information about risk assessment, how they keep safe, their goals and aspirations, how they communicate, their skills and abilities and how they make choices in their life. It also includes information about their health. [See Standard 18] Reviews had been undertaken within a six month period or as individual needs had changed but as previously stated improved records would evidence a focus on asking what has worked for the individual, where there are progress, achievements, concerns and which identifies action points. The home ensures that tenants are consulted regularly to gather information about their satisfaction with the home. They are involved in both the development and review of the service. Where there are limitations, such as the night monitor, there was no evidence that the decisions have been made with the agreement of the person or their representative and these, need to be accurately recorded within each individuals support plan. Oxclose Lane Care Home DS0000008731.V362394.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. Tenants are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: The service has a strong commitment to enabling tenants to develop or maintain their skills, including social, emotional, communication, and independent living skills. Individuals are supported to identify their goals, and work to achieve them. Tenants have the opportunity to develop and maintain important personal and family relationships, and are able to access information and specialist guidance about issues such as intimate relationships. The staff practices promote individual rights and choice, but also consider the protection of individuals in supporting them to make informed choices. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 15 The service respects the human rights of people using the service with fairness, equality, dignity, respect and autonomy underpinning the care and support being provided. The staff team help with communication skills, both within the service and in the community, to enable tenants to fully participate in daily living activities. The service plans to implement a new Family Charter, which outlines how they will engage with families, prior, during and following any new placements at the service. All staff at the service will receive training in this area to ensure consistency across service practice. Tenants told us they are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. They have been fully involved in the planning of their lifestyle and quality of life. Some people attend day services and one person told us about work they did in a local charity shop. Other people attend the local Salvation Army on both leisure and work placements. A number of service users have worked in local voluntary jobs. There was limited documentation to evidence tenant’s daily social/leisure/activities, these should be included within the support format and used as part of the evaluation process to ensure individual needs are being met. Tenants spoken with confirmed they access and enjoy the opportunities available in their local community, such as using public transport, library services, the local pub, and local leisure facilities. The service is committed to the principles of inclusion and promotes and fosters good relationships with neighbours and other members of the community. People living in the home confirmed they had discussed their wishes around holidays in the recent tenants meeting and Butlin’s was a favourite of most people. One person was in Spain at the time of the inspection. Where appropriate, tenants are involved in the domestic routines of the home. They take responsibility for their own room, menu planning and cooking meals, making sure that they are able to enjoy the food they prefer and like. The menu is chosen by tenants on a daily basis with support from staff to ensure it is varied and includes healthy eating. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 16 A pictorial menu book has been created to aid this process. Tenants and staff confirmed that alternatives are offered should the individual not want the main option and that they are involved in shopping for items on a daily basis. Record keeping of individual’s dietary intake/meal choice options could be improved however. [Please refer to Regulation 17, Schedule 4 [13]] Support plans were viewed, which detailed sensitive support for individuals who require support with eating and drinking. Tenants spoken with said they enjoyed their meals. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Tenants receive personal and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each person centred plan or health action plan. However, one person had been identified in the past to be at risk of pressure areas, but there was no current risk assessment tool in place for how this risk was currently managed. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 18 The person did have the necessary equipment in place for pressure relief but this was not detailed within a support plan or risk assessment for pressure areas. There was no record of nutritional assessment tools or tenant’s weight monitoring within the support plans, although there was evidence of healthy eating plans particularly for one person. These additions to the support plan format would give a comprehensive overview of tenants health needs and act as an indicator of change in health requirements. Personal support is responsive to the varied and individual needs and preferences. The delivery of personal care is individual and is flexible, consistent, reliable, and person centred. Tenants confirmed that staff respect privacy and dignity and are sensitive to changing needs. The service listens and responds to individuals’ choices and decisions about who delivers their personal care. People are supported and helped to be independent and can take responsibility for their personal care needs. Health Action Plans are currently being introduced to the service and each tenant has a medication pen picture and risk assessment, the picture describes the support an individual requires alongside the responsibility of the worker. Each tenant is supported to attend a well person check; the service has good relationships with the local generic health services. Staff are sufficiently trained in administering and managing the safe administration of medication at the service. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries, and are signed by appropriate staff. Regular management checks are recorded to monitor compliance. Tenants are given the support they need to manage their medication. If individuals prefer or where they lack capacity, care staff can manage medication on their behalf. Thought has been given to providing safe but sensitive facilities for keeping medication. The home has a good record of compliance with the receipt, administration, safekeeping, and disposal of controlled drugs. Staff have completed and passed an appropriate medication course. Assessments are being carried out to ensure each member of staff is competent to handle, record and administer medication properly. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 19 Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. Tenants are able to express their concerns, and have access to a robust, effective complaints procedure, and are protected from abuse, and have their rights protected. EVIDENCE: The home has an open culture that allows residents to express their views and concerns in a safe and understanding environment. Tenants and others involved with the service say that they are happy with the service provided, feel safe and well supported by an organisation that has their protection and safety as a priority. The service has a complaints procedure that is clearly written and easy to understand. It is available on request in a number of formats (including other languages, large print, audio etc) to help anyone living at, or involved with, the service to complain or make suggestions for improvement. The complaints procedure is supplied to everyone living at the home and is displayed in a number of areas within the service. Tenants understand how to make a complaint and are clear about what will happen if a complaint is made. However three relatives spoken with told us they did not know about the complaints procedures, but they did say they felt they would be able to express concerns to any staff member. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 21 The home keeps a full record of complaints and this includes details of the investigation and any actions taken. Unless there are exceptional circumstances the service always responds within the agreed timescale. The home learns from complaints. One complaint has been made to the service within the last twelve months. The policies and procedures for safeguarding adults are available and give clear specific guidance to those using them. There is a clear system for staff to report concerns about colleagues and managers. Staff that ‘blow the whistle’ on bad practice are supported by the service, however not all staff spoken with were fully familiar with the contents of the whistle blowing policy or which agency was responsible for safeguarding referral and investigation. The staff and the manager were not fully aware of when incidents need external input and who to refer the incident to. This was evidenced by a recent incident, which had taken place at a day service, which had not been referred to either CSCI [Commission for Social Care Inspection] or Adult Social Care and Health Teams. The matter was resolved during the inspection however. The Registered Manager recognised the need to ensure that all staff are familiar with the Safeguarding Adults Procedures and the organisations policies within the AQAA document. The manager must seek to undertake safeguarding referral training without delay to ensure any gaps in knowledge within the service are reduced. Basic training of staff in safeguarding is regularly arranged. Other training around dealing with physical and verbal aggression is also made available to staff as needed. Staff told us they felt fully equipped to deal with any challenges that may be presented by behaviour of tenants. Use of ‘Restraint’ was not fully assessed at this visit, however the Registered Manager stated she was aware of the appropriate procedures in respect of use of bedrails and other restraints such as lap belts. The use of a night monitor alarm was not fully documented as agreed by parties involved however. Staff spoken with were clear about the need to support tenants with their money in a safe way and records viewed were satisfactory. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 22 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): 24,26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables tenants to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The home provides a physical environment that is appropriate to the specific needs of the people who live there. The well-maintained environment provides specialist aids and equipment to meet their needs. The home is a very pleasant, safe place to live the bedrooms and communal rooms meet the NMS or are larger. Tenants are encouraged to personalise their bedrooms. All the home’s fixtures and fittings meet the needs of individuals and can be changed if their needs change. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 23 The Registered Manager stated that they have found that during the last 12 months some issues which have made it hard for them to improve as much as they would have liked for example completing some essential decorating work to the environment. They have however communicated with the housing association to secure funding and timetable for completion of the works, as an interim measure rooms were decorated with tenants by staff. The team and tenants have been working together to improve the appearance internally and externally at the service. The home is well lit, clean and tidy and smells fresh. The garden at the service is very well presented and maintained. Staff and tenant’s told us that they have BBQ’s in good weather. Tenant’s bedrooms are individual, personalised and safe and the environment promotes the privacy, dignity and autonomy of residents. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private The management has a good infection control policy and encourage staff to work to the home’s policy to reduce the risk of infection. Gloves and Aprons were observed to be in use around the home. Staff confirmed they had received training in Infection Control within Food safety and Health and Safety training and at their induction. Refresher training is planned by means of ongoing assessment, which will provide better evidence in the way of records of this training. Food safety was briefly explored and the home has a copy of the Safer Food Better Business Pack. Records for testing/probing safe food temperatures were not in place and therefore it was recommended that the manager seek advice from the Environmental Health Officer in respect of this. The home has a consistent record of meeting relevant health and safety requirements and legislation, and closely monitoring its own practice. In a letter to CSCI in June 2007 the manager stated: “In the spring of 2001 following a risk assessment five low surface temperature radiators were fitted at the home. As the registered Manager I frequently review the environment to ensure that we remain able to identify and reduce the risk of harm to the service users at the home”. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 24 Low surface temperature radiators were observed to be fitted in areas identified as required, however there were no records to evidence that the risk assessment had been continually reviewed. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 25 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, 33, 34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support tenants who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Tenants have confidence in the staff that care for them. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the people who use the service. There is consistently enough staff available to meet the needs of tenants, with more staff being available at peak times of activity. The staffing structure is based around delivering outcomes for residents and is not led by staff requirements. All staff receives relevant training that is focussed on delivering improved outcomes for residents. 80 of the staff team have completed their NVQ 2, one worker has registered for NVQ level 3 Understanding Mental Health and two workers are also due to access level 2 and 3 in care. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 26 All workers have a Continuing Performance Development file; this is part of the organisations training objectives by way of evidencing all learning and linking that to the General Social care Code of Conduct. Training is also reviewed at supervision for all staff, the organisation as a central database for the purposes of monitoring and identifying training needs/profiles. The manager has completed the registered managers award and the level 4 care award in the past 12 months. There is a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the home recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. Some Criminal Records Bureau disclosure checks were noted to be over three years old; it is good practice to check staff at least every three years. Staff recruited confirm that the home was clear about what was involved at all stages and was robust in following its procedure. There are clear contingency plans for cover for vacancies and sickness and there is little use of any agency or temporary staff. Staff meetings take place regularly. Supervision sessions are regular and staff find them helpful with a focus on improving outcomes for people using the service. Notes and action points are taken of meetings and sessions, and progress is regularly reviewing. Mencap as a service user provider organisation are linking diversity in to their training on person centred approaches. They believe this will promote improved awareness of the diversity of the people they support and how they recognise this is part of person centred planning and working. All staff at Oxclose Lane have received Person centred approach training and completed core units in the award winning induction and foundation programme on diversity. The manager said she receives regular training in diversity. And at Area Management Team meetings they update and review practice at their services so as to ensure diversity underpins practice and implementation of policies. Interaction between staff and tenants was positive, staff involved tenants in discussions speaking to them in a caring manner. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 27 Tenants and their relatives spoke highly of the manager and staff team. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 28 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, 38, 39, 41 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The registered manager has the required qualification and experience, is highly competent to run the home and meets its stated aims and objectives. The manager is able to describe a clear vision of the home based on the organisation’s values and corporate priorities. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of ‘best practice’ operational systems, particularly in relation to continuous improvement, customer satisfaction, and quality assurance. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 29 The manager provides an excellent role model for other employees. Other professionals see the manager as an imaginative, approachable and effective leader who consistently provides high quality services. They undertake regular training and understand and value opportunities for their continuing professional development. The AQAA contains excellent information that is fully supported by appropriate evidence. It includes a high level of understanding about the importance of equality and diversity and a wide range of evidence showing how they have listened to residents. The home demonstrates a high level of self-awareness and recognises the areas that it still needs to improve, and has clearly detailed the innovative ways in which they are planning to do this. The home fully recognises the importance of the annual quality assurance assessment and has used the content to inform its own quality assurance. The data section of the AQAA is accurately and fully completed and supports evidence in the self-assessment section. The manager stated in the AQAA “Mencap as a service provider is currently undertaking a review of the way that we seek and gain feedback from the people we support. To date we have used accessible paper based questionnaires, but feedback from the people we support indicates that these do not always give the scope for people to comment on what is important to them in the support they receive. We are moving towards a more flexible process for facilitating and recording dicussions withy people based around what we believe to be best practice.We plan to use the Quality Tree service user questionnnaire for this years audit. We are planning to intorduce more frequent tenants meetings, these meetings are used to establish views and aspirations of the tenants we support.” People are supported to manage their own money where possible. Those who do not currently have the skills are encouraged and supported to develop to become as independent as possible. Recommendations in respect of running records, notifications, risk assessments and limitations of freedom have been made to further improve the service. The home works to a clear health and safety policy. All staff are fully aware of the policy and are trained to put theory into practice. [See also Standard 2430] Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 30 There were no current or previous certificates for the electrical circuits in the home. Testing should be undertaken every five years to ensure the electrical systems are safe. The manager contacted the landlord, on the day of the inspection who reported that this would be undertaken without delay. Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 31 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 4 2 3 3 4 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 4 3 X 2 2 X Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 32 NO Are there any outstanding requirements from the last 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 2 Standard YA23 YA41 Regulation 13[6], 18 37, 13[6] Requirement The manager must access referral training for safeguarding without delay. Ensure notifications are always made to CSCI as required by Regulation 37, of any events, which affect the health and well being of a tenant living at the home. Timescale for action 15/07/08 15/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard RCN YA6 YA12 Good Practice Recommendations Ensure relatives are informed of inspection reports and how to access these Introduce running records, which document the lifestyle experience of the individual, including their social and leisure activities, which should be used to monitor and evaluate that the tenants support plan is being followed by staff and the individuals needs are being fully met. Ensure where limitations are in place such as the night monitor, appropriate documentation and agreement are in DS0000008731.V362394.R01.S.doc Version 5.2 Page 33 3 YA6 YA18 Oxclose Lane Care Home 4 5 YA17 YA18 6 YA18 place. [ Please refer also to regulation 17, Schedule 3[q]] Record keeping of individual’s dietary intake/meal choice options could be improved. [Please refer to Regulation 17, Schedule 4 [13]] Ensure risk assessments are in place for the prevention of pressure areas and how the risk is to be minimised/managed, including details of any equipment is in place. Include nutritional screening tools within the support plan and include weight-monitoring records. These additions to the support plan format would give a comprehensive overview of tenants health needs and act as an indicator of change in health requirements. Ensure relatives are given a copy of the complaints procedures. Ensure records are in place, which provide documentary evidence that the risk assessment for surface temperatures of radiators have been continually reviewed. Records for testing/probing safe food temperatures were not in place and therefore it was recommended that the manager seek advice from the Environmental Health Officer in respect of this. Ensure the electrical circuit systems in the home are safe and send a copy of the safety certificate to CSCI when completed. 7 8 9 YA22 YA24 YA42 YA30 10 YA42 Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Oxclose Lane Care Home DS0000008731.V362394.R01.S.doc Version 5.2 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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