Inspection on 05/03/07 for Smug Oak House

This inspection was carried out on 5th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Smug Oak House 21/11/07

Smug Oak House 02/06/06

Smug Oak House 01/11/05

Smug Oak House 24/05/05

Smug Oak House 13/01/05

Smug Oak House 03/08/04

Smug Oak House 24/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Smug Oak House Drop Lane Bricket Wood St Albans Hertfordshire AL2 3TX Lead Inspector Julia Bradshaw Unannounced Inspection 1 - 5 March 2007 11:00 st th Smug Oak House DS0000019528.V332270.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 Smug Oak House DS0000019528.V332270.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. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Smug Oak House Address Drop Lane Bricket Wood St Albans Hertfordshire AL2 3TX 01923 857 223 01923 854 823 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) www.Adepta.org.uk Adepta Ella Lockwood Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2006 Brief Description of the Service: Smug Oak House offers a purpose built residential service for 10 adults with Autistic Spectrum Disorders and other associated needs. The house has been divided into three units, one for 5 residents, one for 4 and one for 1. This was done to help staff accommodate the differing needs of the residents. The residents all attend a nearby day centre that is also run by PentaHact and is a specialist centre for people with Autism. The house is in a very rural setting some distance from most amenities, but the house has its own transport and service users access the local community frequently. The slightly isolated setting of the home does in some ways suit the particular needs of the service users. The service offered is specialised and individually tailored to meet the very complex needs of the residents all but one of whom have lived there since it opened, in fact the service was set up and designed specifically for them. Information regarding the service is available within the service users guide and statement of purpose. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the third inspection for the year 2006/7 and took place over one day. Documentation examined included three service users’ care plans, service user’s guide, staff recruitment, supervision and training records and quality monitoring records. A tour of the premises was made, taking in all the bedrooms, communal areas and the external grounds of the home. The inspection indicated that the home was running well, with a calm atmosphere. The manager has worked hard since the last random inspection was carried out in November 2006 where there were several requirements were made in relation to the health and safety of the service users. This situation has now improved and the majority of the standards have now been met. Requirements have been made in respect of the environment and staffing and recommendations have been made in respect of service user contracts. What the service does well: There are various systems in place, which reflect the professionalism within the staff team. Working practices were observed as both caring and appropriate to the needs of the service users. The home has produced detailed service user plans and the staff team are in the process of introducing IPP’S for each service user. The service user contract need to be implemented. The manager has worked hard to improve and develop the environment and has endeavoured to create a homely and comfortable atmosphere. A detailed assessment system is in place, which is both detailed and comprehensive in its approach to identifying all the needs of new and existing service users. The home provides detailed information about the operation of the service to prospective and current residents. The staff team appear to be both committed and enthusiastic in their approach to service users who can present as very challenging and demanding. The service users appear to have some degree of involvement in their care planning and the manager is in the process of introducing Person Planning process into the home. The first example of this was seen on the day of the inspection and was of an excellent standard. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 6 The environment continues to be developed and improved to provide a homely domestic setting in which the service users can live safely and lead lifestyles that suit them. In particular, the bedrooms are well presented and have suitable furnishings and décor that both promote the residents’ dignity and provide an acceptable level of comfort and individuality. Two staff on duty were spoken to during the inspection and appeared to have a clear understanding of their individual roles and responsibilities. The home has clearly defined job descriptions. Staff have received a range of mandatory training in order to carry out their roles effectively and professionally. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 8 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 Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 9 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): 1-5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate information about the philosophy, aims and operation of the respite unit is available to prospective service users. The needs of individuals using the service are normally fully assessed and documented prior to admission Each service user should have an individual contract in place to ensure that service users and their representatives know what to expect from the service. EVIDENCE: The home has a statement of purpose and service users guide that detail the aims of the service and the way it is proposed to operate. These documents enable prospective service users and their representatives to make an informed choice about whether to use the respite care service. However all documentation that requires service user involvement/contribution should be produced in a format that is easily understood by the service users. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 10 New service users are normally accepted following a careful referral process and are subject to thorough assessments of individual needs. These form the basis of the care plan drawn up detailing how the needs will be met. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 11 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): 6-10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In general, for each service user a care plan is in place containing comprehensive details of his or her needs, preferences and routines. Although all plans are not signed Staff endeavour to consult service users about their preferred lifestyles and help them to make decisions and choices for themselves. Staff assess and document perceived risks and support service users to lead reasonably independent lives during their stays. Staff follow the home’s policy and maintain confidential information appropriately. Documentation about service users is kept safely and staff respect confidentiality. Individual contracts have yet to be implemented. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 12 EVIDENCE: Three care plans were examined. These contained varied information about individual needs and personal preferences, coupled with clear instructions to staff on how to proceed, including useful behaviour management guidelines as well as tips on personal care, preferred daily routines and social/cultural issues. There was no indication of unduly restrictive rules applied in the home. Relevant risk assessments were on file covering a range of service users’ activities such as going out, The care plans seen conveyed a good overview of the individuals concerned and were generally reviewed on a regular basis. Staff recognise the importance of helping the service users to lead independent lifestyles and encourage them to make decisions for themselves, offering guidance as appropriate. Any restrictions on individuals’ freedom of action are justified by reference to assessment information in their personal files and must be identified and restrictions only imposed if they are in the person’s best interests. Examples of risk assessments with suitable control measures were found in the files examined, covering healthcare issues and activities. The home has a procedure for responding to a service user going missing .The manager must ensure that care plans are signed by either the service user or their representative. Service user’s files are kept securely in the office. The company has a policy on confidentiality that staff are aware of and follow. Information is shared with partner agencies and others on a need to know basis. This topic is also covered during the induction of new staff Personal files examined did not contain service user contracts. Therefore a recommendation has been made in relation to this issue. These contracts should be produced in a “user friendly” format and be signed by either the service user or their representative. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 13 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): 11-17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff encourage and assist service users to make choices with respect to activities in and out of the home, using community facilities in the ordinary way. Service users are able to maintain family and personal relationships. Service users’ rights to make decisions for themselves and undertake appropriate activities are upheld and individual responsibilities are recognised and supported. Service users have healthy diets that correspond to their particular preferences and they enjoy their meals and mealtimes. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 14 EVIDENCE: All Service users attend the same daycentre within Bricket Wood and enjoy a variety of activities provided. Discussions with the service users/families and carers determine the activity plan drawn up during the initial assessment. Access to transport occurs with the use of the onsite transport. Staff support and encourage all service users to maintain and develop social, emotional, communication and independent living skills. The involvement of the service users in daily tasks within the home is fully risk assessed and encouraged, where appropriate. All service users are encouraged and supported to maintain links to the local community. The home is located down a country lane on the outskirts of Bricket wood and St Albans is within 3 miles of the home Routines within the home promote service user independence. Service uses are unrestricted in movement around the home. Menus are offered on a flexible basis, with service users making choices over the meals. Meals observed were unrushed and relaxed. Adequate food stocks were noted in the kitchen cupboards and freezer. Particular food preferences and dietary needs are noted in the care plans. There are various forms of “in –house” entertainment facilities within the home. References to preferred activities were noted in the care plans sampled. Smug Oak has a welcoming atmosphere and service users may have visitors at any reasonable time. Staff assist and encourage the service users to enjoy positive relationships with each other during their stays. If any disputes or conflicts arise staff may act as mediators and if necessary negotiate with the parties to resolve any problems. Behavioural guidelines are devised on an individual basis, where necessary. Staff are aware of the importance of promoting service users’ privacy and act accordingly. For example, they were observed knocking and waiting at service users bedroom doors and the home is currently being adapted to provide key/door locks for every bedroom. However it is recognised that some service users may choose not to lock their rooms or look after their own keys. Adequate food stocks were noted in the kitchen cupboards and freezer. Particular food preferences and dietary needs are noted in care plans. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 15 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): 18-20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All personal and health care support is well maintained within the home ensuring individual needs, choices and preferences are met at all times. Medication is not maintained at 25 degrees or below which may cause the medication to become less clinically effective. EVIDENCE: All care provided is individual and tailored to each person needs with service users choices and preferences being promoted. Assessments and reviews are completed ensuring that the approach adopted is person centred and holistic to each service users needs. Service users are supported with all aspects of their physical and emotional health and receive adequate and appropriate input from specialists such as community nurses, consultants, GP, dentists, opticians and dieticians. Information and advice is provided to all services users regarding general health issues. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 16 A robust policy and procedure is in place to support the safe administration, storage and receipt of medicines. All staff receives training prior to being deemed competent to administer medication. The home uses the Boots pharmacy service and has a good working relationship with them. Contracts are present between the pharmacy and the home and pharmacy inspections are carried out frequently. The home uses a Dosette box system for safe administration. During a discussion with the manager it was agreed that all staff could benefit from medication training in order to ensure that staff have a full understanding of the medication they are administering and the underpinning knowledge of specific medication that they are administering. There was a check of all medication and this was reconciled with the MAR sheets and medication policy. The manager must endeavour to investigate the temperature within the medication cupboard and ensure that medication is stored at below 25 degrees. If the medication cannot be maintained within this temperature, the manager must re-site this cupboard to a more appropriate setting. Medication that is not stored according to the manufacturers instructions may loose clinical effectiveness. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 17 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): 22-23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure within the home is sufficient and adequate in order for the service users to feel that their individual views are listened to. Robust policies, procedures and training are in place to ensure service users are protected and safe. Although a copy of the HCC joint agency working for safeguarding adults was not available on this inspection. This could put service users at risk. EVIDENCE: The Companies own in-house complaints procedure is used and contains all the elements to meet the standard. The manager stated that one complaint had been made since the last inspection took place and this has been resolved to the satisfaction of both parties. The service users living at Smug Oak House have limited communication sklills. Therefore it is imperative that all staff have a comprehensive knowledge of each service user and their understanding. This should be supported through other forms of communication in order to ensure that they are able to express any concerns or issues they may have about the service they are receiving. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 18 There are clear policies on how to respond to suspicion or allegations of abuse. The issue is covered both in-house and in the formal induction training for new staff. Staff spoken with had a good understanding of the basic principles and procedures involved in safeguarding adults. The Hertfordshire inter-agency safeguarding guide must be obtained and kept in the office. It is these guidelines that are followed if safeguarding issues arise and not having a copy on site may put service users at risk. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 19 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): 24-30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home and its surroundings offer a pleasant and comfortable environment to its service users. The home was clean on the day of the inspection. All bedrooms are personalised offering a homely, lived in feel. Water temperatures were recorded at unsafe levels which may present a risk of accidental scalding to residents. Environmental fire precautions must be reviewed to ensure the safety of all those in the home. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 20 EVIDENCE: Service users are encouraged to bring personal items such as furniture and pictures into their room when they move in. The home was clean and odour free on the day of the inspection. The cleaning of the home is carried out by the care staff and with service users assisting where possible. The manager monitors this to ensure that standards of cleanliness are maintained. There have been some environmental changes, which have taken place since the last inspection. The home has been divided into two separate houses with four people and five service users in each house. There are two staff teams responsible for these service users and people are encouraged to respect and recognise these houses as separate. There are still some minor changes to be implemented but in principle these houses are now running as separate units. Hygiene and infection control standards are adequate and gloves and aprons are readily available. The kitchen and laundry rooms are domestic in style and appear to manage their current workload effectively. Sufficient lighting, heating and ventilation is provided. Each service user has a single bedroom. The communal areas of the home are decorated and furnished to an acceptable le standard and there is a selection of home entertainment equipment for service user to access. The home also benefits from having an enclosed garden area with various items of outside equipment for service user to enjoy in the warmer months. The water temperatures on the day of the inspection were recorded at unsafe limits (see requirements). The bedroom door of one service user needs replacing. There is an ongoing issue of ill-fitting fire doors and the Company must review the current arrangements in order to protect and safeguard service users, staff and visitors to the home. There is a need for the home to fit a more effective system of door closures throughout. There is a tendency for staff to prop open these doors for convenience. Although on the day of the inspection these doors were not wedged open but in previous inspections some doors had been wedged open. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 21 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): 31-36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing files contained all of the required information and suitable checks on all staff, ensuring the safety of the service users. Adequate staffing levels are provided that ensure service users are well supported and the aims of the home can be met. There is a detailed recruitment policy and procedure in place that ensure all staff are suitable to work at the home and protect service users’ interests. Staff are well supported by senior colleagues. However the senior staff must ensure they maintain levels of supervision in line with the required standard. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 22 EVIDENCE: Staff spoken with during the inspection appeared clear of their individual roles and responsibilities. The home has been through some difficult staff changes since the last inspection was carried out and the manager has worked hard to build and develop the relationships between staff working at the home. Staff were seen to support the main aims and values of the home. Clearly defined job descriptions are in place. All staff will or have received a series of mandatory training course in order for them to meet the complex needs of the service users. Training in Safeguarding Adults is provided as part of a rolling mandatory training. The company has a comprehensive recruitment procedure. Three staff files examined contained photographs of the person, application forms, two positive references and CRB disclosures. All new staff receive the company’s induction and foundation training and the company appears to provide good access to training according to the training matrix provided by the manager. Recent courses undertaken include fire safety; skip training, makaton, Autism (basic and advanced – 3 day) and PCP facilitator training. The manager ensures that all staff have mandatory training provided. Staff currently receives “Safeguarding Adults” training once every two years. There is currently one member of staff doing NVQ level 3, 1 person has NVQ level 2 and two staff already have NVQ level 3.The manager is currently doing NVQ level 4 provides The manager must ensure that all staff receive the minimum level of supervisions, in line with the required standard of at least six individual sessions per year. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 23 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): 37,39,40,41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well run, with service users benefiting from the support and guidance of the manager and the committed staff team. The manager has been in post since 2005 and is experienced in providing leadership to the staff team. The home is operated in an inclusive manner that enables staff to contribute ideas and the service users to have some control over their lives within a risk assessment framework. Self-monitoring systems are adequate but could be further developed. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 24 EVIDENCE: The ethos and management approach creates an open, positive and inclusive atmosphere. The service users appeared to benefit from this structured and well run home. The staff and manager are adequately and suitably trained in order to meet the complex changing needs of the service users. The manager has daily contact service users, therefore assisting in any issues of concern being dealt with immediately. The majority of service users at the home have difficulty in communicating verbally and therefore the manager must ensure that there are adequate systems of alternative communication provided to enable service users to communicate effectively, including policies and procedures that are relevant to their care. All records are secure and were up to date and held in accordance with the Data Protection act 1998 ensuring that service users rights and best interests are safe guarded by the homes polices and procedures. Records regarding staff recruitment were inspected and there was adequate evidence to confirm that the recruitment and selection procedures were being adhered to. Individual and generic risk assessments were in place, with all external required safety checks occurring. The general standard of fire checks/recording had improved and fire records on the day of the inspection were up to date and recorded accurately. However there is still an ongoing issue with the water temperatures being irregular and on the day of the inspection were recorded outside of safe limits. The manager must arrange for these temperatures to be checked and rectified immediately. The manager must also ensure that all water temperatures continue to be checked on a daily basis. The manager should implement a formal Quality Assurance system in all areas of the service in order to ensure there is regular monitoring and reviewing to improve areas of development. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 3 4 3 5 2 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 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 3 3 2 x Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 26 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 Standard YA6 Regulation 15.(1) Requirement Timescale for action 30/04/07 2 YA24 3 YA24 4 5 YA24 YA36 6 YA20 The manager must ensure that all service user plans are signed by either the service user or their representative 23.(4). The manager must ensure that (a) there is an effective system in place for securing and opening of fire doors i.e. automatic fire door closure should be fitted throughout the home. 13.(4). (c) The manager must ensure that all water temperatures are maintained within safe limits at all times. An immediate requirement was made. 23.(2). One service user has a door that (b) needs replacing. 18. (2) The manager must ensure that all staff receives appropriate levels of supervision. The staff require a minimum of six supervisions per year. 13 (2) Medication must be stored at correct temperatures at all times. 30/04/07 06/03/07 30/04/07 30/05/07 30/04/07 Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA5 YA23 Good Practice Recommendations The manager should endeavour to provide each service user with an individual contract – in user friendly format A copy of the HCC joint agency guidance for the procedures to follow in the event of a safeguarding adults issue should be obtained. Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hertfordshire Area 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 Smug Oak House DS0000019528.V332270.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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