Inspection on 02/02/07 for The Oaks

This inspection was carried out on 2nd February 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Oaks 01/09/08

The Oaks 27/09/07

The Oaks 07/02/06

The Oaks 22/08/05

The Oaks 23/11/04

The Oaks 02/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Oaks, The 165 Worcester Road Malvern Worcestershire WR14 1ET Lead Inspector Jean Littler Unannounced Inspection 2nd February 2007 10:00 Oaks, The DS0000035110.V324517.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 Oaks, The DS0000035110.V324517.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. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oaks, The Address 165 Worcester Road Malvern Worcestershire WR14 1ET 01684 572079 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.exalon.net Exalon Care Homes Ltd Mrs Doreen White Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is primarily for people with a learning disability, but may also accommodate people who have associated physical disabilities. 7th February 2006 Date of last inspection Brief Description of the Service: The Oaks is a care home providing a service to a maximum of ten younger adults of either gender who have a learning disability. Some of the service users also have an associated physical disability. This is one of three homes owned by the registered provider, Exalon Care Homes Ltd. The Oaks has been a home for adults with learning disabilities since November 2002. The home is situated between Malvern Link and Great Malvern, opposite the common. It is ideally situated for access to local facilities and on a bus route to Worcester. The detached house extends over three floors with communal rooms and ten single bedrooms. Information about the service is available from the Home on request, from the providers web site or from the head office at Albion House, Market Place, Westbury, Wiltshire, BA13 3DE. The fees range between £1225 and £1336 per week. On top of the fees the residents have to pay for personal items such as clothes and toiletries, and personal services such as haircuts and chiropody. The cost of group outings and meals out are included in the overall fees, individual outings and meals are extra. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on a weekday between 10am and 6pm. All residents were at home and some spoke to the inspector in the lounge area. Two spoke to the inspector in private and showed her their bedrooms. The staff were observed interacting with the residents during the day and one was interviewed. The manager and a team leader assisted with the inspection process. The manager had completed a pre-inspection questionnaire to provide additional information, which was received by the Commission on 17th January 2007. Some questionnaires were returned to the Commission from residents and others involved with the Home. Information already known about the service, and communications between the service and the Commission since the last inspection were also considered as part of the inspection process. What the service does well: What has improved since the last inspection? The residents now all have a Health Action Plan. They are being asked their views more often and their ideas are being listened to. The residents are now being involved in choosing new staff. Some parts of the house have been redecorated. A cleaner’s job has been added to the staff team. New staff are being given a better foundation training. A policy has been written to guide staff about managing the residents’ medicines. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 7 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 Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 8 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, 4. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The arrangements to assess the needs of a new resident were not robust enough to ensure the placement would be able to meet his needs. Information about the Home was not up to date and was not given to a new resident to help him make an informed choice about where to live. Prospective residents are offered trial visits and overnight stays. EVIDENCE: There is a Statement of Purpose that has been reviewed in 2006. This is very brief and does not comprehensively explain who the service is for and how it will be provided. Clear information is needed about the staffing levels, training arrangements and the sizes of the rooms. The Service User’s Guide is more informative and a version is available in Widget format. The resident who had moved into the Home in December 2006 had not been given a copy of this. The manager said this was because she had not updated it to reflect that one of the company directors had recently left. He could have had a copy and had this explained to him. He had been given a copy of the company’s advertising leaflet. Records showed that as part of the assessment process for the newest resident information had been obtained from external professionals. These assessments showed that the resident had significant needs not usually catered for by the Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 9 service and that fall outside of the Home’s Statement of Purpose. The manager had completed her own assessment, however these needs were had covered. The resident is funded from another local authority but there was no evidence of the arrangements for either routine or emergency health care. The resident came to visit the home on four occasions including a weekend stay to try out the service. Brief records had been made about these visits. The manager reported that a placement review would be held after three months before the placement is made permanent. The resident was reportedly shown a vacant bedroom and another resident’s bedroom. He chose the room that was currently occupied but this resident agreed to move rooms. It is a very unusual practice to offer occupied bedrooms to prospective residents. The useable floor space of the room he chose is greatly reduced by the very low eaves. The single bed is positioned under the eaves posing a risk to the resident. The resident stood in the small alcove en-suite toilet that is fitted under the eaves. He is tall and could not stand up straight under the strip light. The room has not been made particularly homely and the carpet is heavily stained. The bed was a single and looked too short for the resident. The inspector was concerned that the room did not meet the resident’s needs. It had reportedly been redecorated and the lack of personal items was his choice. However, the provider has explained that the room chosen was thought to be suitable by the resident and his representatives. The issue was discussed at a subsequent review meeting and it was agreed that the resident would remain in the room. The light fitting in the en-suite has been replaced to give greater headroom. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 10 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, 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents cannot be fully confident that their assessed and changing needs will be reflected in their care plans. The residents are being supported to take some risks and they are being consulted about some decisions that affect their lives. The level of their involvement in planning their support, goals and ambitions could be increased. EVIDENCE: All the residents have a care plan and a sample of two were viewed. The design of the plans makes the information clear for staff and the headings cover many areas. They are written in a way that shows each resident is treated as an individual and the guidance is specific to their needs and abilities. The plans are not presented in a format that would enable the more able residents to understand what is written about them. They do not contain any person centred goals and aspirations agreed with the residents, or their representatives on their behalf. One showed that three personal care goals were in place e.g. teeth cleaning, but staff have been recording on the charts for many months that no progress was being made. There was no evidence Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 11 that this information was being evaluated and decisions made about whether alternative goals should be tried. Following the inspection the provider explained that this was not in fact a development goal as all involved in her care accept that progress in this area is not possible. The goal had been left in place to remind staff to encourage the resident to be as independent as possible. Goals need to be put in place where there is real potential for development and instructions for staff need to be clear as to the actions they should take to achieve the goals. Risk assessments have been completed as part of the care plans. The layout of these is clear and they show that risks are being balanced against the resident’s right to go into the community and experience normal things e.g. swimming. The content in some is not detailed enough to protect the residents. Those relating to outings referred to one of the safety measures being suitable staffing levels, but what these are is not specified. Work on ‘My Life’ books has started with most of the residents but this is not being given a high priority and the manager said she needs to re-motivate keyworkers. Some specific issues were looked at to see if the care plans covered these sufficiently. Some behaviour that the newest resident has displayed in the past were not mentioned in his care plan and a strategy was not in place if these were presented in the Home. An assessment was in place regarding one resident’s epilepsy. This had been reviewed in June 2006, however the epilepsy and his general condition had changed since then. The assessment did not reflect that a mattress had been put next to the bed and that he is being checked more frequently at night. It did not state if equipment to help detect a night seizure had been reconsidered because the risk level had increased. The same resident has fallen several times and has needed hospital attention. A specialist helmet has been provided but there is no falls risk assessment in his care plan to show how the situation is being made as safe as possible. These issues have been discussed in recent staff meetings and plans made in the residents’ best interests. It appears that the care plans do not reflect all the positive work that is taking place. Keyworkers are now going to write monthly summaries. These may help demonstrate the current issues and how they are being addressed and progress towards goals etc. Currently a main annual review meeting is held where all external professionals are invited. At the six monthly intervals an internal review is held with the resident, their keyworker and next of kin. Consideration could be given to holding full reviews at least six monthly as detailed in Standard 6 i.e. by inviting external professional. The minutes from the residents’ meetings showed that the residents are being supported to influence their lives by suggesting menu, activity and holiday ideas. They were consulted about the new kitchen and given the opportunity to Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 12 take part in recent staff interviews. The level of understanding and involvement of less able residents could be greatly increased if information was provided in alternative ways. Oaks, The DS0000035110.V324517.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, 12, 13, 14, 15, 16, 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are being provided with the opportunity for personal development and have access to suitable activities that they enjoy. Both these areas need further development particularly for those who are less able. The residents are being supported to stay in touch with their families. Their rights are being respected but some could be supported to take on more responsibility for themselves. The food is enjoyed and the menu provides a balanced diet. EVIDENCE: Independence is being encouraged in some areas e.g. life skills, personal care. It was reported that some residents have made good progress. It is positive that two residents are now keeping their weekly college money in their bedrooms. Consideration should be given to how these skills can be expanded. One resident goes out alone. He said he enjoys this and staff see him across the road outside the house. He said he did not carry a card with contact details on and he does not know the Home’s phone number. The provider has Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 14 confirmed that he carries contact information and is given a mobile phone when he goes out. Some staff have attended intensive interaction training and one worker spends time with one resident engaging with him and copying his vocalisations. He responds well to this. Some staff have also been on total communication training and a book of Makaton symbols is used at times with one resident. The need to communicate in a certain way is included in each care plan e.g. use simple key words and limit the number of choices offered. This area could be developed much further using signing and computer images to help facilitate understanding and choice making opportunities for the less able residents. There are two vehicles to enable residents to access outings. An activities budget of £60 a week is provided. Each resident has a personalised activity timetable. Five residents attend day centre and college sessions between three to five times a week. Some activities are accessed in the community e.g. library, bowling, swimming and shopping. Others are more specialised e.g. hydrotherapy. The manager has arranged for a local hall to be hired one day a week on a three month trial. There are initial plans to run music therapy and cookery sessions in the hall with the involvement of some residents from another of the organisation’s Care Homes. The newest resident has a programme that includes work on the home’s two allotments, as he prefers working outside. He is being paid to work in the Home’s garden and to regularly clean the Home’s vehicles. The timetable for some of the residents needs to be further developed. Their timetables show regular use of the sensory room but it has not been used consistently during the winter because the type of heating has not yet been agreed with the fire officer and installed. During the inspection the television was on in the lounge but no structured indoor recreation was seen to be offered to the residents who cannot occupy themselves productively. One resident with autism spent time rocking and wandering in the house and was not directed into a meaningful activity when he returned from an outing. He may need time to relax but these behaviours usually indicate the need for structure. Leisure outings are arranged e.g. pub trips, theatre and music concerts. An annual holiday is provided within the fees. A second holiday can be organised if requested and finances allow. It is positive that the level of outings and activities provided has been increased. The residents are making suggestions about activities they want to try e.g. the gym and horse riding, and these are being arranged. One to one staff time is provided during the month for outings of the residents’ choice and for personal shopping. Records of activities are kept and if a resident declines an outing this is noted. One resident does refuse quite often. Residents are supported to stay in touch with their relatives. One said he talks to his sister on the phone and some go to visit relatives regularly. Relatives are invited to review meetings. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 15 The residents spoken with said they liked the food a lot. The food is purchased locally and cooked fresh for each meal. Some of the residents help shop and prepare food if they want to. The range of meals cooked are discussed at residents’ meetings and if on the day a resident does not want the meal being prepared they are offered an alternative. The menus have a choice of two dishes for the main meal of the day. A cooked breakfast is provided on a Saturday and a roast dinner on Sunday. The menu looked balanced and varied. The inspector sat with the group for lunch. The three staff sat with the two residents who were at home. A worker appropriately assisted one resident with his meal. The opportunity for the residents to choose the type of soup and sandwiches fillings they wanted was missed as both were served the same tinned soup and a mixed plate of sandwiches. A choice of fruit was offered from the fruit bowl. The manager said she had started to take photographs of meals to aid the less able residents to make choices. This work had not yet been completed. Oaks, The DS0000035110.V324517.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, 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are having their personal care needs met in a way they prefer. The residents physical health needs are taken seriously but preventative and specialist health care arrangements need to be developed. Medication is generally well managed but some areas for further improvement have been highlighted. EVIDENCE: The care plans contain details of how staff should best support each resident with their personal care. Records confirmed that daily care was being given and baths taken regularly. The residents looked well presented and staff attended to them promptly when they needed attention with personal care. Those that are able to express their preferences have been asked about same gender care. The three female residents are only supported by female staff. The residents spoken with said they were happy with how they are supported with their personal care. Staff who were preparing to assist a resident to bath were in communal parts of the Home whilst wearing protective aprons and gloves. Consideration should be given to only putting on these items when in private areas to help maintain the residents’ dignity. Eight residents have their toiletries locked away in their bedrooms. The manager said the keys are kept in the rooms but the arrangement is needed, as there is a risk of some residents drinking toiletries or putting the containers down the toilet. These Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 17 arrangements should be kept under close review as the risk assessment process should be, as far as possible, enabling rather than restrictive. Staff were observed to talk about a resident’s needs in front of the person but without including them and in front of other residents. The manager should remind staff about how to share information appropriately. The staff member spoken with seemed well informed about the residents’ care needs and spoke about the residents with warmth and respect. All residents now have a Health Action Plan in place. Arrangements are in place for regular medication reviews, dental and chiropody checks etc. It is positive that the manager says she visually checks residents for signs of ill health whilst assisting them with personal care. Annual well-man/woman checks are not being arranged with GP’s as the surgery reportedly does not provide this service. These are recommended under Standard 19 as part of the preventive health care plan. The checks can be particularly important for those residents who cannot explain how they feel or check their own bodies e.g. breast checks. The manager should negotiate further with the GPs concerned to try and build in this safeguard for the residents. Positive feedback questionnaires were received from four health professionals. One resident has been very unsettled over the last two months. The staff team has found the behaviours very difficult to respond to and at times these have significantly affected the quality of life of the other residents. The manager took the decision to bring behavioural response guidance from 2004 back into use. The resident’s consultant was informed of the changes in her behaviour six weeks after they started. Information received during the inspection suggested that staff had made assumptions about the possible causes e.g. the build up to Christmas, a physical health problem. The provider has explained that during the six weeks a number of physiological problems such as a urinary tract infection were being ruled out by the GP; the behavioural nurse was kept fully informed; and the day centre staff though the resident was fine throughout. A review has now been held and specialist support has been requested. There will unfortunately be a further delay in accessing this because of the waiting list. It is positive that this resident has been settled and has made progress since moving in two years ago. However, the recent change in behaviours has highlighted that the service is not yet set up to respond appropriately to complex behaviours of this level. The providers have recognised this and have taken steps to provide intervention training. Staffing levels, staff retention and the way the environment is used should also be reviewed. The new resident with potentially significant specialist health needs has been admitted from another county without there being any evidence of an agreement being made about how these will be met. Without such an agreement and relevant guidance for staff to follow, he may not have his needs met in a timely manner. The care plan did not address how these needs Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 18 would be met and not all the staff have been provided with some of the essential training. The manager was observed safely administering the lunchtime medication. The medication is stored in a trolley and the key is held securely. The trolley was clean and well organised. No controlled drugs are being held, although suitable arrangements are in place if they are prescribed. Bottles and packets are being dated when opened and supplies are counted and noted when delivered. The medication is mainly supplied in a monitored dose system (MDS). Other medication is stored in the shelves of the cabinet. This arrangement may be clearer if the shelves were labelled for the residents’ concerned. Medication details are in the care plans and ‘homely’ medication profiles have been agreed with the GP’s. The administration charts were clear and appropriate information was being recorded. One dose had not been signed for but the MDS blister was empty so it appeared this had been given. A system is in place where a second member of staff signs a separate sheet to witness that each dose has been given. This is a good system, however the same dose had not been signed for on this sheet, as well as one for the next day. Not all hand written entries on the chart had been signed by two staff to show they have been double-checked for accuracy against the GP’s instructions. The manager said that protocols are now in place to guide staff about when ‘as required’ medicines should be administered and in what doses. Emergency epilepsy medication is prescribed for one resident. The stocks were not being recorded accurately and two unlabelled/unnamed doses were in the cabinet, one of which had passed the expiry date. Some staff are not trained to carry out the procedure and some that have been are not confident. Because of this the doctor or the manager are called to give the medication. The doctor has told the manager not to reorder the medication, as it has not been needed for over a year. It would be safer, considering these circumstances, to arrange with the doctor for the medication to be returned and to take advice about the timing of calling 999 if a seizure is prolonged. The organisation has a medication policy that was marked as having been reviewed in October 06 by the Managing Director. The manager felt this policy did not precisely describe the arrangements in the Home and so she also has her own local policy. The main policy should reflect what actually happens in the Home. New staff are shown the medication system as part of their induction over six sessions. An accredited course is then accessed through workbooks. Not all staff have completed this training yet. The provider has confirmed that untrained staff do not administer medication but they are allowed to countersign that a medication has been administered. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 19 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 residents’ feel their views are listened to however information about how to make a complaint could be made more accessible. Systems are in place to help protect the residents from abuse but the procedures and training arrangements could be improved. EVIDENCE: The home has a complaints procedure however this is not written in Plain English. A version in the Widget format is available to help some residents understand the content. The Home reports that each resident has a copy of this and that staff remind them of their right to complain when they have residents’ meetings. The minutes seen did not reflect this. The newest resident said he had not been given a copy of the procedure. He and another resident spoken with and those who returned questionnaires indicated that they would inform staff or the manager if they had a problem. Each resident has a keyworker and residents’ meetings are held to support them in expressing their views. All but one resident have relatives closely involved in their lives. The manager is open to the involvement of independent external advocates, however currently only one resident has one. Another resident may benefit from input if it can be arranged. One resident attends a self-advocacy group, which is very positive. A record is kept of any complaints. One resident’s next of kin has recently raised several concerns. Correspondence between the relative and the manager was seen on the resident’s file. Another resident’s family have made a complaint recently. This was not examined, however the provider’s representative who monitors the service each month has concluded it had been Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 20 dealt with appropriately. Complaints records seen at the last inspection were assessed as appropriate. The Commission has not received any complaints since the last inspection. The Home has a procedure for dealing with allegations of abuse. This did not refer to the local multi-agency procedure for protecting vulnerable adults. The ‘Whistle Blowing’ procedure did not make reference to the Department of Health’s guidance ‘No Secrets’ or about the protection that will be given to staff under the Public Interest Disclosure Act if they pass their concerns on to the Commission. The manager has recently had to deal with an issue whilst providing managerial support at another of the organisation’s homes. She had not been aware of the multi-agency procedure and although she did inform the Commission the inspector had to guide her to make the required referral to Social Services. Existing staff received training in protecting vulnerable adults in 2005. Training should be arranged for newer staff and to refresh the others. It may be helpful if the Worcestershire Adult Protection Team provides this. Consideration should be given to the manager attending a course specifically for managers to fully equip her for her role. Some aspects of staff recruitment need to be improved to better protect the residents (see staffing section). The long shift system may put residents at risk because of staff tiredness. Whilst the provider has explained that staff have been allowed to choose their own shift pattern and have opted for the one currently in use this approach is not necessarily in the best interest of the residents. It is positive, therefore, that the provider is currently reviewing the shift system. The home has a policy on managing challenging behaviour, which referred to breakaway techniques but these are not consistently used. Recent incidents have highlighted that the training and strategies to respond to aggressive behaviour are not sufficient. It is positive that the manager has already recognised this and has requested professional support and is exploring additional training. The records relating to the handling of one resident’s monies were viewed. These showed that receipts were being kept and the expenditure was appropriate and in line with the Terms and Conditions of residency. Recent cash withdrawals from the resident’s banks account had been logged into his cash records. When relatives give over monies for a resident a carbonated receipt should be given to the relative to evidence that the full amount was logged into their records. This provides protection for all parties. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 21 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, 25, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents live in a home that is safe and reasonably comfortable. There is a lot of scope to make it more homely and fit for purpose. Residents are not always provided with bedrooms that suit their needs. The house is being kept clean but infection control arrangements can be further improved. EVIDENCE: The Home was purchased by the company in 2002, having previously been a Care Home for older people. It is situated in a residential area of Malvern opposite the common. The location means the residents are within walking distance of local shops and on a bus route. The building is a detached, extended Edwardian house on three floors. Suitable fire prevention and detection systems are in place. There is an enclosed lawned garden to the front and rear with seating. The communal rooms include the kitchen; main lounge and dining room, which are on the ground floor, along with one bedroom. Three bedrooms are located in an annexe along with a small lounge/diner that has a door to the garden. There is a small lounge situated on the second floor. There are ten single bedrooms, of which seven have en suite Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 22 toilet facilities. Suitable bedroom door locks are fitted and a few residents have a key. Issues relating to the suitability of one bedroom are detailed under the ‘Choice of Home’ standards above. As the Home is for ten people who have very mixed needs consideration should be given to operating the Home in smaller groups utilising the three lounges and two dining areas. There are four bathrooms, two separate toilets and a staff toilet suitably located around the home. The hot taps are fitted with temperature controls to reduce the risk of scalding. One bath is adapted with a chair hoist. It is positive that the majority of toilets and bathrooms are no longer being locked. One toilet has an unpleasant smell. The manager said this room is not used, however it was available for use so should smell fresh. Monthly provider’s reports indicated that at times water does not reach all taps because of low pressure. The manager responded stating this was because the plumbing system has been over extended. The system should be reviewed to ensure it can effectively meet the demands of the service. Some of the décor and furnishings still reflect that of a home for older people. The providers have been slow to upgrade the Home. Following requirements being made they have been working on a schedule of improvements over the last two years. Many areas have now been improved, however there is still work needed. The kitchen is due to be refitted in the near future, which is urgently needed. Specialist equipment has been provided for the residents with physical disabilities. The home does not have a call bell system but there are usually two waking staff who carry out regular checks on the more vulnerable residents. The garage at the end of the garden has recently been converted into an activities/sensory room for the service users. This has been used since the summer but as there is no heating installed yet it cannot be used in colder weather. It is not clear how much of a benefit this will be to the residents as it may be difficult to access and heat sufficiently in the winter. How staff communicate with those in the main house will need to be considered. If an internal room had been used for this purpose it would have provided better long-term outcomes for the residents. A maintenance person is employed and staff log work needed in a book. The need to protect residents from an uncovered bathroom radiator that was identified at the last inspection has still not been completed so the system does not seem to always be effective. The home has a separate laundry with washing machine, tumble dryer and washbasin. Protective clothing is available for staff in the laundry and in Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 23 bathrooms around the house. The new washing machine has a sluicing facility so the practice of hand sluicing needs to be stopped. Red plastic laundry bags should be provided so soiled items can be moved around the Home without the risk of cross infection. A chair covered in material was seen in one bathroom. It is not possible for staff to wipe this clean so there is the potential for crossinfection between residents. Some rusty equipment was also noticed. Suitable hand washing facilities are provided for staff and residents. The majority of staff have now attended infection control and food hygiene training and places are being sought for March and April 07 for the remainder. A cleaners post was created following the last inspection, however the worker has since left. Some care staff have picked up these hours to do the cleaning while a replacement is found. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 24 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents like the staff who support them, some of whom they know very well. The staff are now being better trained but they still need to become more skilled and competent at responding to complex behaviours. The residents will benefit from staffing levels increasing but the shift system and the high staff turnover are not in their best interest. The way staff are recruited can be improved to help protect the residents. EVIDENCE: There are four staff on duty during the day and two at night. The manager also works during the day Monday to Friday so is available if additional support is needed. Two waking night staff were considered appropriate because of the size and layout of the Home. At times when cover has not been found for the second worker a member of the day team has slept in and been on call. The frequency this occurs should be monitored to ensure it does not become regular practice. The day staff are split into two teams that are led by a team leader. The rota is fixed so the teams do not work with each other unless they have covered a vacant shift on the opposite team. A worker spoken with said this did not happen very often. The provider has stated that this happens frequently. The teams work 8am-8pm over three days. A member of staff was Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 25 heard telling a new worker that to start with the long shifts are exhausting. These arrangements are not considered good practice as they tire staff, make vacant shifts more difficult to cover at short notice and they can create inconsistencies in care and a rivalry between the teams. It is positive that the way the staffing is organised is being reviewed. The evening shifts end at 8pm, which is unusual in a home for active adults as people may wish to go out or be meaningfully engaged until 10-11pm. Now a tenth resident has moved in the staffing levels are due to be increased. Two staff have been selected, one for each team, to support this resident with his day activities. They will work 9.30am-9.30pm. In the afternoons this extra worker will increase the staffing available for the other resident. The home has a maintenance person and a cleaners post has been brought in since the last inspection. The home’s Statement of Purpose states a high staffing level is provided. The current levels are not high for this client group and support staff also have to complete some domestic duties, cook and do laundry as well as give medication and complete required records. Staffing levels should be reviewed again once the new workers have become established. Some of the staff have experience, skills and knowledge of caring for people with learning disabilities and others are learning ‘on the job’. New staff are doing the new common induction standards and then going on to the Learning Disability Award Framework foundation units (LDAF). Some staff need to attend core training e.g. food hygiene and infection control. Since the last inspection training arrangements have been improved and it is positive that nine staff attended Autism training in 2006. More challenging behaviour and total communication training is being planned and staff in the organisation are training to become physical intervention trainers. They will then train the staff team. Staff are not provided with mental health training although some residents have these needs. The percentage of the team who hold an NVQ award has risen from 20 to 33 . Efforts need to continue to reach the national minimum standard of 50 . The manager has a training matrix to show where gaps exist. Brief details of future training plans were submitted. These should be further developed to demonstrate that all workers’ training needs will be met in a timely manner. Nine of the staff have left since the last inspection. There are currently sixteen staff in post and one vacancy. While the high staff turnover continues it will not be possible to provide consistency of care from an experienced and well trained team. The ongoing induction and training demands will take funds away from other developments. The worker spoken with had been in post for three years. He was clear about his role and knew the individual needs of the residents. He reported that he was provided with regular supervision and had attended the training offered. A new worker said she had felt welcomed and had come to a staff meeting that she found helpful. Three residents returned questionnaires that were all Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 26 positive. One reported that he is very happy and feels well cared for. Six relatives returned questionnaires. All contained positive information, although some felt staffing arrangements could be improved in terms of the numbers on duty and their skill level. An external professional reported that the team did not always communicate effectively, demonstrate a clear understanding of the residents’ needs or fully implement the professional guidance that was given. Professionals have given this type of feedback during previous inspections. One worker’s recruitment records were sampled. These showed that evidence of identification is being obtained and that application forms are required. A CRB and two references had been obtained for the worker before they took up post. The applicant had worked in three previous positions with vulnerable adults or children but a reference had only been requested from one of these. The manager should consider which references would best protect the residents rather than just accepting the two referees the applicant puts forward. The manager was not aware that the Care Home Regulations 2001 were strengthened in July 2004 in respect of recruitment and employers are now required to contact previous employers where the applicant has worked with vulnerable adults or children and establish why they left. This is to ensure the employer finds out if the worker has ever harmed or put vulnerable people at risk prior to the PoVA List being set up. A record should be made to evidence that any gaps in employment histories have been satisfactorily explained. It is positive that a new application form is being introduced to help this. It is also positive that one of the residents helped to interview the applicants who will be supporting him with his day activities. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 27 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, 40, 41, 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents’ benefit from the manager’s commitment and experience. They may further benefit if the service is developed to better reflect the residents’ range of needs and ability levels. Procedures and record systems are in place to help protect the residents. Some procedures need to be expanded and some of the records improved. The residents’ health, safety and wellbeing are being promoted, however some shortfalls were noted that could have had serious consequences. EVIDENCE: The manager is appropriately qualified for her position and she has managed the Home since it was opened in 2003. She is also an NVQ assessor. The manager seems very committed to the Home and works regular unpaid overtime. Her support structure is due to be improved as a new post of training and development manager has been created in the organisation. There have been recent changes at a senior level as one of the two directors has left. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 28 The manager was not fully informed about all areas that fall under her responsibility e.g. adult protection procedures and recruitment regulations. The admission of a new resident has not been well managed in all areas. The service is trying to provide for a wide variety of needs and abilities without being segregated into smaller specialised units. It would be beneficial if the focus of the service was reassessed and a clear vision developed. Positive work is underway to increase the choices and the variety of activities offered to residents. Networking with other services may assist the manager in moving the service forward more quickly. To help assess the quality of the service questionnaires are issued to the residents, their relatives and staff. The feedback is then sent to an external organisation that analyses the findings and summarises the information in terms of the percentage of satisfactory answers. In terms of establishing the quality of the residents’ lives this method is limited, as it does not reflect the mixed abilities of the residents or the complexities of the service. The anonymous questions for staff could be more useful however they do not seem to provide the manager with enough information to address any issues e.g. between 2005 and 2006 19 less staff reported enjoying their job. The system is not showing a cycle of ongoing improvement and the findings have not been reported to the stakeholders in a meaningful way. There may be less inspections by the Commission in the future so the providers must become proficient at self regulation. The providers do carry out monthly monitoring checks however these are brief and have not consistently picked up on shortfalls that have later been identified by the Commission. The records requested were available and the systems seemed well organised. Some areas for improvement have been detailed throughout the report e.g. medication, recruitment, care planning. Some incidents have been appropriately reported to the Commission however recent incidents resulting from one resident’s behaviour changes were not. The manager needs to ensure good communication is maintained with the Commission. An agreement was made that the provider’s monthly reports would be used to inform the Commission how many occasions each month the Home has been unable to provide two waking night staff. The organisation has the required set of policies. As detailed earlier the sample seen either did not accurately reflect the arrangements in the Home or did not include essential information. The reviews of these have therefore not been fully effective. Information provided showed routine health and safety checks are being carried out and equipment routinely serviced. The fridge and freezer temperature checks were sampled. Staff had been recording that the freezer was not cold enough for three weeks without reporting this to the manager. Once this was brought to her attention she replaced the gauge, as it was Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 29 broken. Risk assessments for individual residents’ have been mentioned earlier. Environmental risk assessments were not reviewed in detail on this occasion. It was noted that one refers to the window opening sizes being restricted to protect residents from falling. A bathroom sash window on the first floor was found to be unrestricted and open. A person could easily climb out onto the metal fire escape staircase and fall or exit the home without being seen. The Fire Officer last visited the Home in August 2006 prompting the introduction of a new fire risk assessment. New fire safety regulations were introduced in October 2006 so consideration should be given to the manager attending training on these. The manager reported that fire awareness training is being improved and staff are starting to be trained to fire marshal level. The door to the dining room was open throughout the inspection. This is a fire door so if it is preferable to have it open for the residents then an automatic closure device needs to be fitted. It was positive that fire evacuation signs have been displayed in a pictorial format to help the residents understand them. After discussions the manager agreed to review the first aid training arrangements. The majority of staff have undertaken a basic first aid course and the manager is a qualified first aider. The risk assessment should consider the residents’ special needs, what areas the current course includes, how near the ambulance service is etc. The organisation does not have a person identified to lead on health and safety. This should be considered, as it is a complex area that is continually changing. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 30 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 2 2 2 3 1 4 3 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 2 25 2 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 x 32 2 33 2 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 x LIFESTYLES Standard No Score 11 2 12 2 13 3 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 3 2 2 2 2 2 x Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA42 Regulation 13 Timescale for action One window needs a restrictor 28/02/07 fitted in line with the Home’s risk assessment. A check should be carried out to ensure no other windows have been overlooked. The dining room fire door needs attention to make sure it shuts reliably. The manager confirmed on 15/2/07 that she would take appropriate action. The needs of any prospective 31/03/07 new residents must be carefully assessed against the Home’s Statement of Purpose and the suitability of the vacant bedroom. The Statement of Purpose must 30/04/07 be updated and expanded. This must clearly set out the focus of the service and how it will be achieved. Clear information about staffing levels and training must be included as well as the room sizes. The Service User Guide must be Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 32 Requirement 2 YA3 YA2 14 3 YA1 4,5,6 updated and a copy given to the new resident. 4. YA6 YA19 12, 15. The care plans must contain 31/03/07 clear information about how each resident’s assessed specialist needs will be met by the service and where applicable by external professionals. Health risk assessments must be updated as health needs and care arrangements change. 5. YA20 13 A system must be in place to 31/03/07 ensure medication past its expiry date is removed from use and returned to the pharmacy. Review the suitability of the 31/03/07 bedroom offered to the newest resident. If he stays in this room then a risk assessment must be completed. The recruitment procedure and 31/03/07 its implementation must be more robust and in line with current regulations and best practice. (Brought forward, previous timescale 31/3/06). All staff must be provided with 31/07/07 specialist training to meet the assessed needs of the residents i.e. Mental Health, Autism, Challenging Behaviour etc. Gaps in core training must also be addressed. (Brought forward, timescale 31/3/06). previous 6. YA25 23 7 YA34 19 8 YA35 13,18 Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 33 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 YA6 Good Practice Recommendations Hold full reviews at least every six months that support residents to develop personal goals and ambitions. Develop care plans into a format that enable the residents to understand and contribute to what is written about them. Continue to support the residents to develop their Life Books. 2. YA12 Arrange for a safe system of heating to be fitted to the sensory/activities room so it can be used. (Brought Forward). Continue to develop the opportunities the residents have to make choices and develop their independent living skills. Develop the use of communication aides to assist some residents to understand and make choices offered to them. 4 5 6 YA12 Continue to develop the range of meaningful activities that are provided particularly for the less able residents. Issue a receipt to relatives when they hand over monies for a resident. Keep a copy with the records. The procedures relating to Adult Protection should be updated to fully reflect current legislation and guidance. Provide refresher training on Adult Protection and Abuse. Consider arranging this through the Worcestershire Adult Protection team so links are developed with the Home. Consider the benefits of the senior team attending a more in-depth course on managing adult protection issues. 7 YA18 YA32 YA33 Keep the need for residents to have their toiletries locked away under review. 3. YA11 YA16 YA41 YA23 YA23 YA11 Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 34 8 YA19 Increase staffs’ awareness of how to promote the residents’ privacy and dignity. Consideration should be given to implementing any specialist advice relating to resident development and emotional needs. (Brought forward). Arrange for all residents to have annual health checks with their GP as part of the preventative health care plan. Ensure shift-monitoring systems pick up if medication charts have not been signed for the doses given. Ensure stock control systems include a bring-forward system for supplies that are not used up during the month. Two staff should sign hand written entries on the charts to check the doctor’s instructions have been correctly entered. Review the need to hold emergency epilepsy medication in the Home. If it is necessary then the management systems need to be made more robust. 9 YA20 10 YA22 Reword the residents’ complaints procedure into Plain English. Consider if a more simple version with pictures would assist some of the residents to better understand their rights. 11 YA24 YA11 Continue work to improve the environmental standards and make the house more homely and representative of the younger adults it accommodates. Review how the layout of the Home is used and consider if smaller living groups can be introduced to reflect the different types of needs and ability levels amongst the current residents. Review the plumbing system and ensure it has the capacity to meet the needs of the service. 12 YA30 Stop the practice of hand sluicing soiled laundry and introduce the use of red bags to limit the handling of soiled items. (Brought forward). Ensure all furniture in bathrooms can be disinfected. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 35 13 14 YA33 YA39 YA40 Explore how to reduce staff turnover levels. The quality assurance programme should be further developed to enable the providers to demonstrate competence at self-appraisal. As part of this, policies and procedures should be reviewed to ensure they reflect current best practice and changes in legislation. Oaks, The DS0000035110.V324517.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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