Inspection on 22/08/05 for The Oaks

This inspection was carried out on 22nd August 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

The Oaks 01/09/08

The Oaks 27/09/07

The Oaks 02/02/07

The Oaks 07/02/06

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 The Oaks 165 Worcester Road Malvern Worcestershire WR14 1ET Lead Inspector Penny Wells Unannounced 27 July & 22 August 2005 12:00 & 15.00 nd 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 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 Stationary 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. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) theoaks@exalon.net Exalon Care Homes Ltd Mrs Doreen White Care Home 10 Category(ies) of LD Learning Disability registration, with number of places The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: In addition to those referred to on the previous page, the following condition applies: 1. The home is primarily for people with a learning disability, but may also accommodate people who have associated physical disabilities. Date of last inspection 23 November 2004 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 responsible individual is Mr Robert Lovis and the registered manager is Mrs Doreen White. The Oaks has been a home for adults with learning disabilites since November 2002. The home is situated between Malvern Link and Great Malvern, opposite the common. It is ideally situated for access to local facilites and on a bus route to Worcester. The detached house extends over three floors with communal rooms and ten single bedrooms. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection that took place during the day of 27th July 2005. Penny Wells was accompanied by Dianne Thompson for this visit and neither of the inspectors had visited this home previously. Time was spent time preparing for the inspection - reading information about the home including the monthly reports from the Operations Director. Six hours was spent at the home. The focus of this visit was to get to know the service and meet with the service users. Inspectors met with service users, staff on duty and were shown around the home. Also sample documentation was read and the daily routine observed. As the manager was on holiday and the inspector new to this service, a second visit took place to meet with the manager. The inspectors appreciated the co-operation and time of the service users, staff and manager. What the service does well: The company have established a comfortable and safe home for service users. Individual service users have their own daily routines which staff encourage and support. The service users that were able to communicate verbally, spoke positively about living at The Oaks and the support they receive. The home has an experienced manager and some staff also have experience in caring and supporting service users with learning disabilities. The training opportunities offered to staff are commendable. Work was continuing to take place to upgrade the house. By the second visit the gardens and exterior had been attended to and looked bright and welcoming. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 6 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 Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,5 The home had suitable information about the service for prospective service users, their families and representatives. The information was available in different formats for the service users. The service should carry out its own assessment prior to admitting a service user. EVIDENCE: The home has a brief statement purpose, which had been revised and submitted to CSCI in April 2004. The service user guide had been developed and was in a suitable format for some of the service users. There had been a recent admission and an inspector viewed the assessment documentation which had been provided from Social Services. This information was not up to date. There was an undated recreational therapy assessment, but no evidence that the home had carried out it’s own assessment. The service should carry out its own assessment to ensure that the prospective service user’s needs can be met and compatibility with other service users. The home had a contract and a signed copy was held on the service user’s file in the office. It was pleasing to note that the guide, contract and house rules were all available in widget format for the service users. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,9 Information was being kept to ensure that the service users assessed needs were known to the staff and consistent care was provided. The risk assessments were detailed to cover risky situations and support the service users that were able to be independent. However, some of the risk assessments needed to be developed to cover individual situations. EVIDENCE: All the service users had service user plans and a sample of three were viewed. Plans were clear and provided detailed information on all aspects of service users lives. One of the plans needed to be updated, as there was differing guidance re a toileting programme and the support the individual needed from staff when out of the home. The outcome of a recent dental appointment could not be located in the service user’s file. Another plan had been reviewed on 15/3/2005. This plan indicated that reviews would take place every 6 weeks. However, it was unclear whether this was routinely happening, dates of future reviews were not apparent. The manager referred to a six monthly reviewing process and said that reviews are sometimes held more often initially. Consideration could be given to introducing person centred plans and involving the service users in discussing their goals and aspirations. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 10 A service user agreement is held on file. Detailed risk assessments had been completed and those seen included going out, bathing, toileting, use of kitchen, burning mouth, dehydration, and choking. The risk assessment on choking for one service user advised that staff ‘remove food from mouth’. Clear guidelines and protocols should be established which ensures all staff respond in a safe and consistent way should an incident of choking occur. An incident was observed during the inspection, which identified the need for a risk assessment to be completed, together with management and supervision guidelines for a service user having food in their bedroom. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 The service users have opportunities to take part in activities out of the home according to their individual level of ability. The service users are supported in keeping in contact with their families. For service users without day or college placements, the home need to develop a range of daily activities in and out of the home, taking into consideration the individuals interests and promoting independence. EVIDENCE: The service users have varying levels of disability hence the opportunities for personal development varied according to the ability and behaviours of the individual. On the day of the visit three service users were at day centres, another out in Malvern on his own. Four of the service users attend either Malvern or Worcester Colleges of further education during term time. Three of the service users did not have day placements and for one his plan did not indicate any planned daily activities. On the day of the inspection, one service user was out in Malvern on his own, another was taken out by two staff and a third was The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 12 attending a medical appointment with a member of staff. Two service users were at home for the day and the television or music was on but no other activities were apparent. In the afternoon these two service users were observed in the lounge sitting in armchairs rocking and needed engaging in activities that interested them (see also page 16). The service users were free to walk around the home and did so. Staff advised that activities out of the home on a regular basis included swimming, bowling, hydrotherapy, walking on the common or in parks, shopping, lunches out, snoezelem and sometimes going to the theatre. The staff day shift ended at 8.00 pm but staff said they stayed on if an evening outing was planned. The home had two vehicles for taking the service users out. However the manager advised that not all the staff were able to drive these vehicles and the home were currently short of drivers. Staff explained that taking some of the service users out depended on the experience and number of staff on duty, hence on occasions it was difficult to take individuals out who needed one or two staff to support them. The manager explained that when she was on duty she or experienced staff were able to take these service users out. The service users had been on holiday earlier this year in small groups with staff to Wales. The majority of service users had regular contact with their families and some went home for weekends. Friends and families were welcome to visit and some parents did visit regularly. One service user was packing to go away with a relative for the weekend and looking forward to this. This person said they were happy at the Oaks, having lived at the home for two years. Another service user advised that they were settling in and liked the home. The inspectors were informed that the home promotes a healthy diet. There was concern however that the menu observed for the week of the inspection contained faggots, egg and chips, pasta bake, hash, curry and kiev for the main meals and did not reflect this. All service users were given hot dogs for lunch on the day of the inspection and inspectors informed that there were yogurts and fruit available for deserts. It was said that alternative choices were available for service users if they did not like what was offered. The main meal was taken in the evening and prepared by the carers, as the home did not have separate catering staff. Drinks and biscuits were served during the day. Two service users are trying to lose weight following a healthy diet and being more food conscious. Menus and records of food provided for the service users were being kept. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 The service users were receiving appropriate support with their personal and physical health care needs. For some service users further consideration should be given to their emotional needs and activities. EVIDENCE: The personal care needs of service users were outlined in their plans and staff were discreet when assisting individuals. Service users could receive care from staff of the same gender, when on duty. The home had a key worker system and consulted with the service users’ families and relevant professionals to ensure that the service users received consistent support to suit each individual’s health care needs. Health care guidance and records were evident in the service users’ plans. The service users were well and it was apparent that their physical needs were met. Some of the service users suffered with epilepsy and staff had/were receiving training from a specialist nurse including administering invasive treatments in the event of a seizure. Epilepsy protocols were not in place but the manager advised that these were under review and that the invasive treatments rarely needed to be used. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 14 The manager had established contacts with health care professionals to consult with, if a service user had a specific health care need. Some of the service users had challenging behaviour and for one service user, a specialist team had undertaken a thorough assessment and prepared detailed working guidelines for staff. Senior staff advised that some of the guidance had been tried without success. It was disappointing that the specialist team had not been invited to a full staff meeting when this feedback could have been given and other activities/interventions discussed. This service user appeared to have no regular day activities and it was unclear from his plan what activities were offered, if he engaged in an activity or declined. The medication system was not inspected on this occasion and will be viewed by the pharmacist inspector soon. However it was noted that a controlled drugs cupboard and register were in place (previous requirement and recommendation). It was pleasing to hear that staff had received training in ‘care of the dying’. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The home had a suitable complaints procedure. A complaints file needed to be kept. Staff observed, listened and responded to the service users in a courteous manner. The home had relevant policies and procedures for protecting vulnerable adults. EVIDENCE: The home had a complaints procedure and the procedure was also in a suitable format for some of the service users. The complaints procedure in the manual needed to include reference to complaining to CSCI at any stage, as it does in the procedure outlined in the service user guide. A complaints file needed to be introduced to record complaints received, reference where the action and outcome was recorded (in the service user’s file) and for auditing purposes. The home had suitable procedures for protecting vulnerable adults. The procedure for protecting vulnerable adults needed to include a reference to the local Worcestershire procedure and any allegation being referred to Social Services. The manager was aware of this process, having used it appropriately earlier in the year when a concern had arisen. Since the last inspection guidance on using the whistle blowing procedure had been prepared by the company for staff. The home had a policy on managing challenging behaviour, which referred to breakaway techniques, and all staff would need specific training if these techniques were to be used. Standard 23 has not been scored because some aspects such as managing the service users monies and valuables were not viewed and will be at the next inspection. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29 There was sufficient space in the home for the service users and staff. The upgrading of the home needs to be completed so that the home is more modern and suitable for the client group accommodated. EVIDENCE: This care home was purchased by the company in 2002, having previously been a home for older people. It is situated in a residential area of Malvern opposite the common, walking distance to local shops and on a bus route Malvern/Worcester. Hence the location is attractive. The building is a detached, extended Edwardian house on three floors. The communal rooms are mainly on the ground floor with one bedroom on this floor. Three bedrooms are located in an annexe with access by steps from the dining room. There is a main lounge and dining room on this floor and two other lounges situated in other parts of the home. There are ten single bedrooms, of which seven have en suite facilities. Some of the bedrooms had been redecorated and bedrooms were personalized. Suitable bedroom door locks had been fitted. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 17 There are four bathrooms, two separate toilets and a staff toilet suitably located around the home. The bathrooms had been redecorated following a flood and as part of the upgrading programme. One bathroom unfortunately had a new leak (which caused damage to the paintwork) and a bath chair needed recovering. Bolts on some of the bathroom/toilet doors needed removing as these rooms now have suitable privacy locks. To safeguard a service user the toilets and bathrooms were kept locked but this restricted the use of these facilities for other service users. A review should take place about the management of this difficult situation to ensure the majority of service users can have free access to these facilities. The home had fully enclosed, lawned gardens to the front and rear. In both gardens there was seating for service users. The gardens were colourful and inviting. The company had a schedule of repair and decoration for the year and a copy had been submitted to the CSCI following the last inspection. At the visit it was apparent that some work had been carried out, in particular relating to some of the service users’ bedrooms and previous requirements, but further work was needed. It was said that there had been a delay in proceeding with the work internally because urgent external work had needed to be carried out. The windows externally were being repaired and painted. The schedule submitted was discussed with the manager and a revised schedule was requested. For example: The bedroom doors needed attention and decorating following the locks being changed. The stair lift was not in use and should be removed as it is in the way, as observed on the day of the visit. If it is to remain, the lift must be serviced prior to being used. Redecorating the bathroom The carpet on the stairs and landings needed decorating and carpets replaced. It was pleasing to hear that the lounge and kitchen were due for refurbishment. Previously the home was for older people and the atmosphere, décor and furnishings still reflected this. Parts of the home are fatigued and in need of upgrading with homely, replacement furniture, carpets and pictures that are age appropriate and stimulating for the service users. The manager had given the upgrade some thought and these proposals are welcomed and need to be implemented. For example the manager was proposing to convert a garage at the end of the rear garden into an activities/sensory room for the service users. This was welcomed although consideration could be given to having an activities/sensory room in the house, which would be easier to access in the winter. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 18 Staff advised that a monitor with a listening in device was being used for one service user at night (the home had waking staff at night). The manager advised that these alarms were only used on the landings and not in an individual’s bedrooms. Alternative arrangements/alarms/monitoring devices should be considered, if required, that respect the privacy and dignity of the service users. There was a poor odour on the third floor landing, which needed attention. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35 The service users were being supported and cared for by a suitable number of staff, the majority of whom knew the service users well. The staff had a range of training opportunities to assist them in caring and supporting the service users. The home would benefit from a settled and experienced staff group. EVIDENCE: The home had two staff teams with four staff on each day shift of twelve hours, 8am-8pm. At night there are two waking staff. On the day of the visit a second team leader was working to cover for the manager being on leave. The home had rotas, which indicated the shift pattern, and that the home had a bank (relief) staff and on occasions used agency staff. New staff had recently been recruited and a person who works at the home during the summer holidays. The two permanent staff on duty advised that they had previously worked in care homes for older people but were finding the change interesting and confirmed there were plenty of training opportunities. The manager was experienced at accessing training locally and had sent CSCI the projected training programme for 2005 at the beginning of the year. She explained that it was about to be reviewed and agreed to send a copy to CSCI which would indicate the training staff had undertaken. Training opportunities included – LDAF, NVQ’s in care, safe working practices and courses relating to working with adults who have a learning disability. For example – behaviour The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 20 awareness, person centred planning, total communication. The majority of staff had this year attended training in protecting vulnerable adults, sexual health and relationships, equal opportunities and care of the dying. The manager advised that the vacancies on days had recently been filled and there were only night vacancies. Staff recruited did not always have experience in working with this client group. There had been a turnover of support workers during the last year. A settled, experienced, permanent staff group would be beneficial to the service users whose needs and dependency levels vary considerably which is demanding for staff. There were no ancillary staff except for the company maintenance person and a gardener. Care staff therefore covered domestic duties - cooking, cleaning and the laundry. The company had a suitable recruitment process and staff records were being kept. However staff were commencing work with a ‘POVA first’ check prior to the enhanced Criminal Record Bureau checks coming through. Ideally staff should have both checks through before commencing work unless there are very exceptional circumstances. This standard has not been scored as the company wish to discuss this matter further which is welcomed. Staff worked long days, two/three days on and then days off. The staff spoken with liked this shift pattern. However this may need to be monitored to ensure that staff are not too tired towards the end of their working days as the work is demanding and can be stressful. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,40,41,42 This service was run by an experienced manager, supported by the company to ensure that the service users’ best interests and safety were foremost. EVIDENCE: The registered manager was experienced, with appropriate knowledge and skills. She had just completed the Registered Manager’s Award. The operations manager visits the home regularly and monthly reports of these visits are sent to the CSCI, as required. The home had the company’s manual of policies and procedures and it was evident that these are reviewed/updated. The home was keeping the records required of a care home. Any comments relating to policies, procedures and records have been detailed under the relevant standard in this report. The standard on Safe Working Practices is wide ranging and the following was noted on this occasion: The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 22 • • • • • • • Staff had opportunities to undertake training in first aid, food hygiene, moving and handling, health and safety. Infection control was said to be included in the health and safety course. Fire training included initially a computer-based course, ‘in line of fire’, annual fire training from a professional and drills which were going to be monthly rather than quarterly. Some senior staff had also attended the fire warden course. A record was being kept indicating that staff received fire training quarterly, as required. The fire records indicating the routine checks on fire equipment were being kept and there was a fire risk assessment. The gas appliances had had an annual check. Fire notices on display were in a suitable format for the service users. The manager confirmed that the recommendations following the environmental health officer’s visit had been actioned. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 x x 3 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 2 x Standard No 11 12 13 14 15 16 17 x 2 3 2 3 x 2 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Oaks Score 3 2 x x Standard No 37 38 39 40 41 42 43 Score 3 x x 3 3 x x E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 24 yes 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 2 Regulation 14 Requirement Timescale for action For the next admission and on going 31.10.09 2. 9 13 3. 11-14 16 4. 24 23 5. 27,24 23 A written assessement must be completed by the home before the admission of a service user and in accordance with Regulation 4 and Standard 2, Some risk assessments must be developed to include situations that may place a service user at risk and include guidance for staff as to how to manage these situations. The range of activities must be 31.10.05 developed, in particular for the service users without regular day placements. A revised schedule for upgrading 30.11.05 the home, with timescales, must be drawn up and reflect the homes purpose. A copy to be submitted to the CSCI. The premises must be well 30.11.05 maintained and safe, specifically: bath chair must be recovered, any bolts on toilet and bathroom doors removed and any poor odour addressed. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 25 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. 3. 4. 5. 6. Refer to Standard 19 22 24 27 29 33 Good Practice Recommendations Further consideration should be given to implementing the specialist advice sought with regard to the emotional needs of a service user. A system for recording and auditing complaints should be introduced. The proposal to have an activites/sensory room should be implemented. A review of the present practice of keeping the bathroom and toilet doors locked when not in use, should be undertaken. The use of monitors/alarms with listening devices should be reviewed and alternative arrangements/alarms/monitors should be considered. The home would benefit from a settled, experienced staff group. The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 26 Commission for Social Care Inspection The Coach House John Comyn Drive, Perdiswell Park Droitwich Road Worcester WR7 3NW National Enquiry Line: 0845 015 0120 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 The Oaks E52 S35110 The Oaks V241159 270705.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!