Inspection on 07/02/06 for The Oaks

This inspection was carried out on 7th February 2006.

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 02/02/07

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 P Wells Unannounced Inspection 7 &14 February 2006 12:30 th th Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 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.V282856.R01.S.doc Version 5.1 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.V282856.R01.S.doc Version 5.1 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.V282856.R01.S.doc Version 5.1 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. 27th July 2005 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 responsible individual is Mr Robert Lovis and the registered manager is Mrs Doreen White. 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. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 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 7th February 2006. The inspection was completed on 14th February 2006. Time was spent preparing for the inspection - reading information about the home including the pre inspection questionnaire and the monthly reports from the operations manager. Eight hours were spent at the home. The home has been open for younger adults for three years and currently has nine service users with differing special needs (including challenging behaviour and autism) and abilities. The focus of this visit was to meet with the manager, staff and service users to hear how the service was developing. Also, to follow up on the previous requirements and recommendations. This report to be read in conjunction with the last report. The pharmacist inspector also visited on 23rd February 2006 and this visit has been referred to in this report. The co-operation and time of the manager, service users and staff was appreciated. 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 others appeared settled. The home has an experienced manager and some staff also have experience in caring and supporting service users with learning disabilities. Comment cards were received: Four service users returned positive comments, one said privacy was respected ‘sometimes’ and another service would like to be involved in decision making in the home ‘sometimes’. Six relatives replied and five were pleased with the service. Three social care professionals replied and two were satisfied with the service. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 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. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 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.V282856.R01.S.doc Version 5.1 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 the following standard(s): 1,2 The home has suitable information about the service for prospective service users, their families and representatives. However the statement of purpose and service user guide need updating and circulating to service users, their representatives and CSCI. The manager indicated that she would be involved in completing the assessment for a prospective service user. EVIDENCE: The home has information for the service users and their families but it needs to be updated to include details of the new company office, staffing and the quality assurance surveys. There had been no admissions since the last inspection so standards 2-4 were not assessed. However the admission process was discussed with the manager who explained that she intended to meet with a prospective service user and their families/carers and to complete a written assessment (previous requirement). The manager was very aware of the importance of the compatibility within the service user group especially as the existing group have such varying needs and abilities. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 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 the following 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. This included risk assessments to cover risky situations and to support the service users that were able to be independent. However the plans should be developed to give a clear picture of a person’s current needs, activities and goals. EVIDENCE: The sample of service user files viewed indicated that there was detailed information kept, forms for recording specific matters and reviews taking place. Two of the service users were clear that they were being supported with their individual needs and goals, as well as having a varied programme of activities in and out of the home. A social worker for one of these service users endorsed this and commented positively on how the person had been involved in the review process. However it was difficult to easily ascertain how the individual’s current, identified, personal and health care needs were being met. For example the individual’s weekly activities – for one service user a detailed weekly programme had been set up following admission but it was unclear whether this was still being followed or had been developed. In the front hall the weekly activities of service users were displayed but not up to date for some of Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 Page 10 the service users nor in a user-friendly format. Consideration should be given as to whether this personal information needs to be on public display. In addition it was difficult to ascertain whether goals were being set and achieved. Another social worker commented that the care planning process needed developing when a service user had complex needs. Staff may benefit from training in person centred planning. Risk assessments were in place and the manager advised that additional situations had been risk assessed since the last inspection. More detail on how staff should manage risky situations would beneficial. Aspects relating to health care matters/service user plans have been commented upon on page 14. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 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 the following standard(s): 12,16,17 The service users have opportunities to take part in activities out of the home according to their individual level of ability. The range of activities and routines could be further developed to promote independence and to give service users without day placements more choice. The service were providing regular meals and drinks for the service users but the choice of food offered should be developed and recorded. EVIDENCE: Some of these standards have been assessed previously and on this occasion it was apparent that efforts had been made to increase the activities in and out of the home. Some service users continue to attend day placements and college and indicated that they enjoy these regular activities. For the service users who are at home there is the opportunity to go out daily for a walk, ride or to the shops (staffing arrangements and weather permitting). Some of the service users spoke about enjoying swimming and bowling. A residents meeting had been held that week to discuss holidays for 2006 and the new carpet and furnishings for the lounge. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 Page 12 On the second visit staff were making valentine cards and a few service users were participating. It is hoped that when the activities organiser is back in post, activities will be further developed for the service users who spend the majority of their time at home, taking into consideration their individual interests. It was disappointing that the sensory room had not been finished, as service users would benefit from this additional facility. The more able service users had their own individual routines whilst other service users were supported in following the home’s routines. On the day of the inspection all the service users were up, dressed and had breakfast by 8.45 am. Lunch and tea (the main meal) were taken together. Service users were free to move around the home and use all three lounges, although the main lounge was the hub with staff and service users, who needed monitoring encouraged to sit here. Staff respected the privacy and individuality if the service users and included them in conversations. Service users having bedroom and front door keys should be assessed, recorded and promoted. Rules on smoking, alcohol and drugs and other house rules were clearly stated. Menus and records of food provided were kept and it was observed that service users enjoyed the meals served. However the food provision needed developing to give service users a choice at mealtimes, to record that fresh fruit and vegetables are provided daily, that snacks are available mid morning and at supper. Drinks were served throughout the day. The manager was already considering these points with a member of staff. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 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 the following standard(s): 19,20 The service users receive 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. The recording of health care needs needed improving. Protocols need to be in place for the administration of medicines in specific situations. There is a suitable medication system in place. The medicine policy needed developing. EVIDENCE: It was evident from observation and discussion that service users continued to be supported appropriately with their personal and health care needs. Health care professionals were consulted at an early stage if a problem arose. A sample of service users’ health care records were viewed and needed to be improved to evidence this clearly. For example health care matters were either being recorded in the service user plan or health action plan and occasionally some appointments were not recorded. Hence neither the forms in the two plans were always fully completed and information could not be easily accessed. A review needs to take place of these records so that it is clear to staff where to record a health care matter. It was confirmed that some staff had received training in compiling the Worcestershire health action plans - these need to be fully Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 Page 14 completed, kept up to date, retained by the service users, taken with the service user to appointments and when away from the home. Service users were being weighed but no comments made when a service user’s weight altered. At the last weigh-in it appeared that two service users had lost a significant amount of weight but there was no follow up recorded. This matter was brought to the attention of the manager. Some staff had received recent training in epilepsy, challenging behaviour and autism. Physical intervention is not used. Medications are prescribed for a service user for epileptic seizures and on occasions of agitation but protocols were not in place. Hence the manager had decided staff should not administer these medicines until protocols had been agreed. This matter needs to be followed up as a priority so that the service user can safely be administered the medications, when needed. Fortunately seizures have been rare and medical persons have been called immediately. The recommendations from a specialist team, who had thoroughly assessed a service user’s emotional needs and behaviour had not been given further consideration, which was disappointing. However the manager advised that she and a senior member of staff had attended a course on Intense Interaction and were hoping to implement this with this service user but there was no indication in the service user plan. The medication system was inspected on 23rd February 2006 by the pharmacist inspector who has sent a separate report to the home. In summary she found the overall management of medicines good using a monitored dosage system. Three requirements were made relating to the administration of the medicines and the manager has already advised that two matters have been addressed. The outstanding requirement relates to developing the medicine policy. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 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 the following standard(s): 22,23 The home has a suitable complaints procedure and records indicated that complaints are acted upon. Staff observed, listened and responded to the service users in a courteous manner. The home had relevant policies and procedures for protecting vulnerable adults and a robust system for handling service users monies. The majority of staff had received training in 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. A record was now being kept of complaints and clearly indicated how the issue was investigated and the outcome. The manager outlined how she was addressing current concerns raised by a relative. The home had suitable procedures for protecting vulnerable adults. The majority of staff had received training in protecting vulnerable adults last year. The home had a policy on managing challenging behaviour, which referred to breakaway techniques but these were not being used. The manager was aware that staff would need specific training if these techniques were to be used. The system for handling service users’ monies was viewed and appeared clear and robust with individual records being kept. Consideration should be given to the service users being supported in managing their own monies, which could be kept in a lockable place in their bedrooms. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 Page 16 Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 There was sufficient space in the home for the service users and staff. The upgrading of the home must be completed and ongoing repairs/decoration completed quickly. Aspects of hygiene and infection control need improving with the staff receiving training. EVIDENCE: See previous report for details of the accommodation. On this occasion the inspector was shown around the home and noted that: The home was warm, clean and safe. The service users’ bedrooms were personalized. Seven of the bedrooms have ensuite facilities. A service user had moved into the vacant bedroom whilst repairs were carried out in his bedroom. The dining room had been decorated and new blinds and lighting installed. New dining room furniture was awaited. The stair lift (which was not used) has been removed, giving easier access on the stairs and landings. Parts of the home were cold at the beginning of one of the visits but this was soon addressed by the manager re-setting a boiler. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 Page 18 The upgrading of the home had not been completed as per the 2005 schedule which was disappointing. The home has been open for three years and the environment needs to reflect that it is a home for younger adults. The upgrading had been reviewed with a company representative and a programme for 2006 was available. This indicated that the work would be completed by November 2006. It was pleasing to hear that the service users were being consulted about the new carpets and furnishings in the lounge. Priority should be given to completing the sensory/activities room, which was not included in the programme, and the main lounge. At the first visit there was a sofa without seating in the main lounge (the covers were being washed following an accident). Extra covers would be beneficial or items of furniture removed whilst being cleaned. A wardrobe in a bedroom was top heavy, hence unstable. Wardrobes need to be secured to the wall and a separate place identified for the storage of suitcases/additional items. The majority of the radiators and hot pipes were boxed in but in one bathroom this needed addressing. All the bathroom, toilet and ensuites should have privacy locks. Now that a service user is settled, the locking of these doors has lessened and should be reviewed for the bathroom on the ground floor. The high bolt on the exterior of this door was broken, hence not in use, so this should be removed, which will give all the service users easy access with staff monitoring, where needed. The seat of a bath chair had been removed and replaced with colour-coded covers for individual service users to use. The home does not have a call bell system but is accommodating service users with physical disabilities so such a system may well be helpful (to both service users and staff as the bedrooms are located on three floors). However the introduction of two waking staff may address this. The home has a separate laundry with washing machine, tumble dryer and washbasin. Protective clothing was available for staff. A washing machine with sluicing facility was on order and disposable bags for soiled laundry were recommended. These additional facilities would be more hygienic and staff would not have to manually sluice soiled laundry. Staff need training in infection control and food hygiene. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33,34,35 The home now has a permanent staff group who need additional training opportunities, guidance and supervision to assist them in gaining the skills, experience and knowledge needed to care and support the service users. The recruitment process needs to be more robust. EVIDENCE: It was pleasing to note that the home had nearly a full staff group with only one vacancy for nights. It is hoped that the current staff group settle as the high turnover of staff (10) since the last inspection was of concern. Service users benefit from an established staff group to give them consistent care and support. It was commendable how the manager, team leaders and permanent staff had maintained the service during this difficult period. There are four staff on duty during the day. There are two teams covering the twelve-hour day shifts. There is a team leader and three support workers, covering from 8.00am-8.00pm. All the staff are full-time. These long shifts over two consecutive days need monitoring. In the evenings from 8.00pm and overnight night there are two staff and a team of six covers these shifts. On some evenings there is an additional member of staff rostered on until 8/9 pm in the week but not at weekends. This evening arrangement may need to be reviewed so that there are sufficient staff on duty of an evening if service users wish to go out. The rotas were available and clear. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 Page 20 Some of the staff have experience, skills and knowledge of caring for service users with learning disabilities and others are learning ‘on the job’. New staff need to undertake training, including the Learning Disability Award Framework (LDAF) induction. The manager had produced a projected training programme for 2006. During the last six months some staff had received training in first aid, administering medication, autism and epilepsy. Three staff have an NVQ in care and seven staff are undertaking an NVQ. 20 of the staff have an NVQ in care which is below the national minimum standard of 50 . However the manger is aiming at 60 of the staff having an NVQ in care this year. The support workers provide care and support to the service users, some of whom need 1:1 support when going out. The support workers also cover domestic duties including cleaning, cooking and laundry. Consideration should be given to employing a cleaner rather than relying on care staff to clean as well as look after service users, cook and do the laundry. The home has a maintenance person but no other ancillary staff for administrative and domestic duties. The staff on duty were clear about their roles and knew the individual needs of the service users. The company have a recruitment procedure and have set up staff files. However there were gaps in the sample staff records viewed. The recruitment and selection process was discussed with the manager and indicated that there needed to be a more robust vetting system to ensure that only persons with suitable skills and attributes are employed to protect the service users. There also needed to be a vetting process for recruiting students who work in the home during their summer holidays, and for carers from abroad. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,42 Quality assurance, health and safety systems are in place to protect the service users. Aspects of safe working practices need addressing. EVIDENCE: The company had introduced a quality assurance system. An independent company had carried out an audit of the record keeping systems and the manager showed the inspector the draft report indicating the service had done well. Surveys had also been sent out to stakeholders and the results not yet available. In addition the operations manager reports on her monthly visits to the home and there are checks in place relating to health and safety. However some other aspects of quality assurance outlined in standard 39 and regulation 24 need to be included, such as an annual development plan and review of the quality of care. The standard of safe working practices was assessed and it was apparent that there were systems in place to ensure the health and safety of the service users and staff. Equipment, gas and electrical services were being checked Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 Page 22 regularly. Risk assessments for safe working practices and accident book were in place. There was also a monthly audit of rooms. There was a projected training programme for 2006, which included training in safe working practices. The following matters needed addressing: The home did not have a certificate of electrical safety but the manager advised that the electrics had recently been checked and the certificate this was awaited. The portable appliances needed an annual test. Records of water temperatures were not up to date and need to be checked and recorded weekly. The recommendations following the environmental health officer’s visit, implemented. Ensure all staff receive training in safe working practices, in particular food hygiene and infection control. Advice sought regarding the disconnected washbasin in the basement and the flow of hot water/dead legs. Aerosols and craft materials were observed in an unlocked cupboard in the dining room and the manager, on the first day of the inspection, arranged for these possible hazards to be kept in an alternative, locked cupboard. The majority of staff had undertaken a basic first aid course. The home should aim at a member of staff trained in first aid being on duty at all times, preferably a first aider, as many of the service users do have special needs (learning and physical disabilities); or a risk assessment carried out. The fire precautions were being regularly checked and a fire risk assessment was in place. Monthly drills were taking place and this was being logged as inhouse training for staff. Quarterly fire awareness training in-house is recommended and a record kept in a format, which easily identifies this has taken place. It is important that night staff receive this training at quarterly intervals. An annual fire training session and senior staff to attend a fire warden’s course was indicated on the projected training programme for 2006. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 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 2 2 X 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 2 25 X 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 2 X X X 2 X X 2 X Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 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 YA1 Regulation 4,5,6 Requirement The statement of purpose and service user guide must be updated and circulated to service users, their representatives and CSCI. The health care records must be kept up to date and include any follow up. Protocols for the administration of treatments in certain situations must be in place. A detailed medicine policy must be available and must include specific procedures on receipt, recording, storage, handling, administration and disposal of medicines. The revised schedule for upgrading the home must be completed within the proposed timescales. (timescale of 30.11.05 not met) The premises must be maintained and minor repairs, cleaning and decorating be undertaken without delay; specifically those issues listed on page 19 of this report The recruitment process must be DS0000035110.V282856.R01.S.doc Timescale for action 30/04/06 2 3 4 YA19 YA19 YA20 12,15 12,13,15 13 30/04/06 30/04/06 31/03/06 5 YA24 23 30/11/06 6 YA24 23 30/04/06 7 Oaks, The YA34 19 31/03/06 Page 25 Version 5.1 more robust. 8 YA35 13,18 The projected training programme for 2006 must be implemented to cover LDAF induction, safe working practices, caring and supporting service users, in particular those with challenging behaviour. The home must aim at 50 of the staff having an NVQ in care. Aspects of safe working practices listed on page 23 of this report must be addressed. 31/03/06 9 10 YA35 YA42 13,18 13 31/07/06 30/04/06 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 7 8 9 10 11 Refer to Standard YA16 YA12 YA17 YA19 YA19 YA19 YA23 YA24 YA30 YA39 YA42 Good Practice Recommendations Develop the service to give the service users more choice, activities and promote independent living skills Consideration be given to bringing into use the sensory/activities room as a priority. Consider extending the menus so that the service users have a choice for meals and snacks. Complete the Worcestershire health Action plans and introduce the plans to the service users. The arrangements for weighing the service users should be reviewed and any concerns followed up and recorded. Consideration should be given to implementing any specialist advice relating to service users development and emotional needs. Consideration should be given to service users managing their own monies, with support. All bathroom and toilet doors should be kept unlocked when not in use, for easy access. A washing machine with sluicing facilities should be installed and disposable bags used for soiled washing. The quality assurance programme should be developed as per Standard 39 and Regulation 24. A clear record should be kept indicating that each member of staff has received quarterly in-house fire awareness DS0000035110.V282856.R01.S.doc Version 5.1 Page 26 Oaks, The training. Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 Page 27 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: 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 Oaks, The DS0000035110.V282856.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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