Inspection on 26/10/06 for The Oaks

This inspection was carried out on 26th October 2006.

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

The inspector found 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Oaks 21/10/05

The Oaks 15/06/05

The Oaks 12/01/05

The Oaks 11/10/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Oaks (The) The Oaks 1a Spencer Way Redhill Surrey RH1 5LF Lead Inspector Kenneth Dunn Unannounced Inspection 26th October 2006 10:00 Oaks (The) DS0000013736.V316682.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) DS0000013736.V316682.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) DS0000013736.V316682.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oaks (The) Address The Oaks 1a Spencer Way Redhill Surrey RH1 5LF 01737 789404 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) The Avenues Trust Limited To be confirmed Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 31- 55 YEARS 21st October 2005 Date of last inspection Brief Description of the Service: The Oaks is a care home providing personal care and accommodation for 6 adults with a learning disability. Previously, the individuals in the home lived in Earlswood long stay hospital. The home is run by The Avenues, who manage a number of similar homes in the area. The property is situated between Salfords and Redhill. Vehicle access is needed to reach either. The home occupies a detached building, benefiting from communal areas at either end and a sensory room at the rear. The staircase at each end of the ground floor accesses service user bedrooms at first floor level, a further two bathrooms and the staff sleeping in room. The home benefits from a good-sized secure garden, with patio seating and a barbecue area. There is a small amount of parking at the front, which is off the road, with opportunities to park in the local roads. Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced site visit to be undertaken by the Commission for Social Care Inspection year April 2006 to March 2007. Mr Kenneth Dunn Regulation Inspector carried out the site visit. Ms Asli Kirkham the newly appointed manager for the home was present. The site visit was undertaken over 4 hours. A full tour of the premises took place, staff and service users were spoken to, and care records and documents were inspected. Some service users living at the home have communication difficulties and judgements were made about them based on their mood, behaviour and information given by staff. The inspector would like to thank the staff on duty and service users for their contributions to the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home needs to review the statement of purpose to reflect the appointment of a manager to the home. The service must complete the redecoration and the refurbishment of the home, a new kitchen is required and the relaxation room at the rear of the home must be reassessed for its fitness of purpose and overall safety. Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 6 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) DS0000013736.V316682.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) DS0000013736.V316682.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service user guide are good providing service users and prospective service users with the details of the services the home provides enabling an informed choice to be made about admission to the home. The arrangements for assessing needs are robust ensuring service users need are assessed fully and identified prior to admission to the home. EVIDENCE: The information contained in the statement of purpose was clearly written and nicely presented in a widget/Pictorial format to make the information accessible and understandable to service users. Each service user has a copy of the service user guide, which is in pictorial format to be more accessible to them. However the home needs to review the statement of purpose to reflect the appointment of the new manager to the home. The home has not had any new admissions since it opened. The Avenues have an admissions procedure, which the manager demonstrated a good awareness of the individual’s needs to have thorough assessment prior to being considered for admission to the home. Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 9 Oaks (The) DS0000013736.V316682.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users individual plans are clear and comprehensive including details of needs and goals. They also incorporate known or indicated preferences and choices, and include in depth risk assessments. EVIDENCE: Staff stated that the service users are supported to make decisions affecting their lives in a number of ways. Each service user has an allocated key worker, who is trained to offer one to one support and who knows the service users well and understands their needs. Service users meetings are held to enable them to make decisions and choices, for holidays, menu planning and outings. Service users individual choices of meals were recorded on the weekly menu plan. The manager advised that information is provided to service users to assist with decision- making and this is in a format to suit their individual needs. Information is provided in pictorial or visual formats and staff also give information verbally, as appropriate. Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 11 Information is displayed and provided for service users in picture form on a notice board in the kitchen, informing the service users of the day of the week, and the evening meal. Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 12 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, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The supports offered by the manager and her staff enable service users to take part in valued and fulfilling activities. The arrangements in place ensure that service users can become an active member of the local community. The policies and routines at the home promote personal relationships with families and the rights of service users. Meals are good and offer both variety and choice. EVIDENCE: Service users at the home have opportunities for fulfilling activities and education and some service users attend a local college. The service users clearly identify The home has its own transport to enable service users to access community based facilities. The home support service users to maintain family links and friendships and the inspector noted relatives visited service users at the home regularly. Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 13 Observations confirmed service users had unrestricted access in the home and staff supported service users in maintaining their independence. The home has a written weekly menu plan and a record of meals eaten by service users. Service users are involved in planning the menu and in the preparation of meals. The inspector noted the menu offered variety and choice and meals were nicely presented. Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. The arrangements for personal support are designed to ensure that the service users are supported in the way they prefer. The arrangements for meeting the health care needs of service users are robust and supportive. The management of medication at the home is good and promotes the health of service users. EVIDENCE: The service users are supported by the staff in a way that is designed to promote their privacy and dignity. The inspector noted that all care staff knocks on doors before entering service users bedrooms. Details of the service users preferences in respect of their personal support needs are recorded on their care plans. This was also confirmed by observations made by the inspector during the inspection where staff were seen to support service users to maintain their independence in choosing clothing, meals and activities. The home has health action plans and service users have access to a GP, dentist, optician and chiropodist to maintain good health. The home has a robust policy for the safe storage and handling of medications. The procedures in operation are for all staff to receive full training in Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 15 medication handling, at the time of the inspection the manager was awaiting dates for new members of staff to undertake their courses, the manager stated that until they have satisfactorily completed the course they are not permitted to handle medication. Medication recording sheets were sampled they were all dated and signed by staff no errors were found. The home kept a record of medications returned to the pharmacy, which was signed and dated, by care staff and the pharmacist. Medications are stored in a locked metal cabinet secured to the wall in the staff office, which is appropriately labelled for information, and the home had a list of homely remedies approved by a doctor. The manager has instigated a policy where all PRN medications are stored in individual wallets that have tamer proof seals attached to the openers, ensuring further safeguards are in place. Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. All required policies, procedures and practices are in place to ensure that the service users are safeguarded, as far as reasonably possible, from harm or abuse. EVIDENCE: There were no recorded complaints since the previous inspection; the manager informed the inspector that the service has not received any external complaints in this period. Records seen indicated that complaints would be responded to within the guidelines. The homes complaints procedure for service users is in a pictorial form the inspector was informed that the service users would be able to use it when necessary. Staff spoken to, stated that they had undertaken training in the protection of vulnerable adults and would report any concerns they had to the manager. If they had concerns about their manager, they would be reported to the area manager they were able to explain the concept of whistle blowing and understood their role in the event of having to instigate such an action. Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 17 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, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the home provides a safe and homely environment for the service users to live in and enjoy, however there are several areas of considerable concerns mainly the kitchen and the relaxation room. EVIDENCE: On the day of the inspection the home was clean, well presented and free from mal odour. Individual bedrooms are personalised to reflect individual personalities hobbies and interests. There has been some improvement to the general environment of the home with new carpets fitted in some areas and the some fresh paint on the walls, theses areas are unfortunately only on the ground floor at present. The first floor of the home is still to be decorated and recarpeted. The kitchen still has the original units in place and these are now looking somewhat tired, and dated. The units are ill fitted causing gap to be left which constitutes hygiene risks. It was reported to the CSCI inspector on the 15th of Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 18 June 2005 by the service manager “that as part of a planned audit by The Avenues, the home’s kitchen has been identified as needing replacement”. Therefore a requirement has been placed to ensure that the kitchen is now replaced with more suitable units and designed to meet the needs of those working in that environment. The relaxation room which is a lean too construction at the rear of the building must be inspected by a structural engineer to ascertain its safety. The main structural supports for the roof are in a very poor state of repair and the inspector was able to push his pen into the rotten wood. The structure in total must be checked by an appropriate professional because it is now is a very poor state over all. This area is now also subject to an urgent requirement in order to repair the relaxation room or to remove it and replace it with a new safe structure. Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All interactions observed between staff and service users evidenced a high degree of respect and skill in working with specific individual and the service users as a group. Staffing is kept under review and provided to meet the needs of the residents at all times. EVIDENCE: It was pleasing to note that staff have a good understanding of the service users needs, are respectful and demonstrated a good rapport with them. Staff recruitment files are up dated and contain all the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001. All staff has had a criminal record bureau (CRB) check and Protection of Vulnerable Adult (POVA) check prior to starting work in the home. NVQ training has become rather haphazard over the past year however with the appointment of a new manager it is hoped that this will improve. The manager sated that NVQ training was now seen as a priority and staff will be assisted to start and complete their training. The manager gave evidence of a professional and comprehensive induction period for new members of staff. Induction and foundation pack is supplied to all new staff the manager plans to take all new staff through the process. Bank staff are also inducted into the Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 20 house. Staff training plans seen and they clearly demonstrate a commitment to the overall training of staff by the organisation. Staff confirmed that they receive training on a regular basis and the inspector viewed certificate detailing additional training courses undertaken by the staff group. Additional training needs are identified during the recently introduced annual training analysis, which set out to ensure that where a gap is identified training would be sought to ensure that gap is filled. The inspector examined records of training and found evidence of a very full and varied training programme being undertaken by the service. Over all training at The Oaks meets the needs of the service users. Staff files indicate that a number of courses have been undertaken and all mandatory training has been the majority are up to date with all other. Staff supervision was seen to be undertaken on a regular basis, and staff are provided with a copy. Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new manager must submit an application for registration to the CSCI (Commission for Social Care Inspection) to ensure service users benefit from a well run home. The arrangements for quality assurance are in place ensuring service users participate in the development of the home. The systems for health and safety are robust ensuring the health and safety of service users and staff is promoted EVIDENCE: The home has appointed a manager to provide management stability, leadership and direction to the staff team. The manager has experience of supporting people with a learning disability and worked with the organisation for 10 years hold a Registered Managers Award and an NVQ 4 in management. A member of the care staff stated ‘‘ things have improved and the home is better’’. Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 22 The home has a policy of quality assurance and used questionnaires to obtain feedback about the home. The inspector was informed by a member of the care staff that the manager consults with the service users by having regular monthly meetings. In addition the organisation carries out frequent monitoring visits. The inspector noted Regulation 26 (record of monthly monitoring visits) kept at the home was up to date and reflective of the current situation found at the Oaks. The home has a policy on health and safety and staff have training in health and safety. Staff have mandatory training in fire, food hygiene, moving and handling, and first aid. Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 1 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 24 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 YA24 Regulation 16(1), 23(1&2) 16(1), 23(1&2) Requirement The manager must ensure that the service users live in an environment that is homely, comfortable and safe. The organisation must ensure that the kitchen is replaced with a purpose built and designed kitchen, which is user friendly and can be maintained in a hygienic way. The organisation must ensure that the lean too structure at the rear of the home, which is designated as the relaxation room is fully inspected by an appropriate professional. A copy of the said professionals final report must be forwarded to the CSCI local office. Service users or staff must not use the relaxation room until such times as the service receives a certificate of safety from an appropriate professional. The registered person must ensure an application for registration as manager is submitted to the CSCI (Commission for Social Care Inspection) without delay so that DS0000013736.V316682.R01.S.doc Timescale for action 25/12/06 2 YA24 25/12/06 3 YA28 16(1), 23(2) (e,h) 25/12/06 4 YA28 16(1), 23(2) (e,h) 9(2)(b,j) 25/12/06 5 YA37 25/12/06 Oaks (The) Version 5.2 Page 25 service users can benefit from a well run home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oaks (The) DS0000013736.V316682.R01.S.doc Version 5.2 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. 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