Inspection on 01/12/05 for The Oaks & Woodcroft

This inspection was carried out on 1st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Oaks & Woodcroft 10/05/07

The Oaks & Woodcroft 16/05/06

The Oaks & Woodcroft 16/08/05

The Oaks & Woodcroft 27/01/05

The Oaks & Woodcroft 08/07/04

The Oaks & Woodcroft 02/12/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 The Oaks / Woodcroft The Oaks / Woodcroft 2a Dereham Road Mattishall Dereham Norfolk NR20 3AA Lead Inspector David Welch Unannounced Inspection 1st December 2005 3:45 The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 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 The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 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. The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Oaks / Woodcroft Address 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 Oaks / Woodcroft 2a Dereham Road Mattishall Dereham Norfolk NR20 3AA 01362 858040 01362 858954 Conquest Care Homes (Norfolk) Limited Mrs Karen Elizabeth Bash Care Home 12 Category(ies) of Learning disability (12) registration, with number of places The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th August 2005 Brief Description of the Service: The home is situated in a village some 15 miles or so west of Norwich city centre. It is set back from the road and consists of two bungalows, known as The Oaks and Woodcroft. The bungalows both have accommodation for six adults between the ages of 18 and 65 years, each with a learning disability. The Oaks tends to accommodate people with additional physical disabilities. Every resident has their own bedroom, which they can personalise, and in each bungalow there are shared lounges, dining rooms, bath/shower rooms, toilets and kitchens. The bungalows share a large garden to the rear of the properties and there is car parking to the front of the bungalows. The garden, which has relaxing swing seating and barbecue equipment, is safe with a secure perimeter. The home is owned and managed by Craegmoor Healthcare through its wholly owned company, Conquest Care Homes (Norfolk) Ltd. On the day of the inspection, the home had no vacancies. The Registered Manager for The Oaks and Woodcroft is Karen Bash. The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was timed to take place in later afternoon/early evening when service users would be finishing any day care services in house, or elsewhere, and returning to their homes. The purpose of the visit was as follows: • To seek further information with regard to an anonymous letter sent to the Commission’s Norfolk Area Office raising concerns about staffing levels, support and supervision, management and care at the home in recent months. To fulfil the Commission’s responsibility to check compliance with a number of requirements and good practice recommendations made following the last inspection in August and some outstanding from previous inspections To check the home’s position in regard to a small number of other National Minimum Standards To speak with as many service users as possible To speak with as many staff as possible • • • • There were 12 people in residence and therefore no vacancies. Three staff were initially on the premises, with the Deputy Manager arriving back at 16:00hrs after picking up a service user from day care. The home’s manager was contacted by staff and arrived at the home. One additional member of staff came on duty at 17:00hrs. Too many requirements continue not to be met. Some of these could, and should, have been resolved at a corporate level where access to resources should be available. In some cases the manager had been left to meet with requirements without assistance from line management or the company. This applied in particular to the provision of a Service User Guide, terms and conditions of residence for service users and a Complaints Procedure in a variety of formats that would help most people to understand. The residents and staff were welcoming and keen to cooperate with the inspection. Both groups of residents had their evening meal during the inspection. Nobody was interviewed in private except the Manager and Deputy and most exchanges with staff and residents took place as they were going about their various tasks or just relaxing after the day’s activities. A couple of residents were very willing for their bedrooms to be seen. The evening ended in The Oaks with staff and residents sitting in front of the television. Things seemed very relaxed. After tea in Woodcroft, where people tended to be more active, staff were based in the lounge catching up on their paperwork with residents variously coming and going, as they wanted. Staff said that in general people did not do evening activities such as go out to the The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 6 pub or to see friends at a club, although there was to be an outing the following week. What the service does well: What has improved since the last inspection? What they could do better: Some matters have been left outstanding for some considerable time. The support given to the manager of the home by the company leaves something to be desired. Staffing levels appear not to be sufficient to allow the manager’s ‘baseline’ of 3 carers in each bungalow every shift to be met. Training in certain vital aspects has not been given, while staff support at dayto-day level could be much better. Regular staff meetings at the required frequency to which everybody comes and regular and timely individual supervision sessions would improve staff morale, the consistency and quality of care delivery and a sense of the team being ‘together’. A staff group the majority of whose members have followed NVQ training and who adhere to the Code of Practice of the General Social Care Council is likely to deliver care to residents that is founded on the principles of good practice. The Oaks and Woodcroft is a care home about which the Commission continues to have concerns and efforts must be made at every level to improve the service. The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 7 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 / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. Once the start that has been made by the manager in providing information for residents in a variety of formats is complete, their ability to make decisions will be improved. This applies also to the assessment of residents’ communication needs. There is room for the company to play a greater part in both these processes. EVIDENCE: Following the last inspection, a requirement was made that the Service User Guide was produced in a variety of formats so that all residents were likely to understand what the home offered and how the services they pay for are to be delivered. Formerly, the only statement was in prose form and not everybody living at The Oaks and Woodcroft had the literacy skills needed to read it. The Commission saw it as a corporate responsibility to provide this information, say in sign or symbol form, possibly audio, video or even DVD formats. Staff on site could not be expected to have all the skills, or the specialised equipment, required to produce the Service User Guide in this variety of formats. The home had ‘Widget’ and some information had been ‘translated’ into symbol form. The Manager had consulted the local authority Speech and Language Team who had given some advice about what symbols were suitable and what was perhaps too ambiguous or not descriptive enough. Craegmoor Healthcare appeared not to have had any part in assisting the manager and her staff or in facilitating the process. The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 10 The manager had made a good start on producing the Service User Guide, the terms and conditions of residence and some other documents in photo and symbol formats, but this exercise was not yet complete. No new service users had come to live at the home since the last inspection. A requirement had been made following the last inspection that every resident had an assessment of his or her communication needs. This, to ensure that staff were communicating with the people who lived in the home in the most appropriate way. The manager said that the member of staff who had been trained in communication assessment (but who had not carried out this piece of work when last the home was inspected in August) had now gone on the Bank staff and was not permanently employed. There was to be some training for staff in communication assessment on the day following the inspection, but this had been cancelled. Thus, this important aspect of care had not been carried through and while staff tried hard to engage with residents in a friendly way, no efforts other than speech-based techniques were being used. For some, maybe most, residents this would be sufficient, but there are some people living in The Oaks and Woodcroft for whom speech might not the best way to communicate with them so that they can make their wishes known. The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 10. The work done by the staff, firstly to identify challenges presented by certain residents and then to agree a consistent approach, will have given them a head start in managing this behaviour. An assessment of service users’ communication needs will further ensure that staff can engage with them in the most appropriate way. Some aspects of care practice need attention. The procedures for managing residents’ money at a corporate level to ensure they can enjoy all the available financial benefits could be more transparent. Having separate local bank accounts is something to be welcomed and should go on for as long as possible. EVIDENCE: A requirement had been made that staff had all the information necessary that related to the different challenges posed by certain people living in the two bungalows. This was outstanding from three previous inspections and nothing had been done about it. The matter was again discussed during this unannounced inspection and the Deputy Manager said in the case of two residents who presented particular challenges, staff had drawn up a number of ‘Behaviour Triggers’ and then they had set about identifying situations in which these might cause problems. They had completed the exercise by giving The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 12 examples of staff responses or strategies that could be used to divert, distract or relieve the situation. This is sensible practice. Despite the Operations Director’s assurance after the last inspection that staff would communicate appropriately with each resident to enable them to make decisions about their day to day lives, for instance, what clothes they wanted to wear, there appears to have been little progress in this direction. Without the communication assessment mentioned above, staff are unlikely to have all the information required to assist service users in the most suitable ways. No examples were seen of staff using any other method than speech to communicate with service users and while this is appropriate for most people living in the home, there are residents for whom the spoken word might not be the best medium. Without the assessment staff cannot know. There was one matter that was of concern. The way that a particular member of staff related to some residents seemingly showed a lack of sensitivity. In one case a resident went into the kitchen and took a biscuit. A carer then spoke to the person concerned as if they were a naughty child. The member of staff rationalised the stance taken by saying that the resident had not eaten his sandwiches at teatime therefore could not now have a biscuit. The same carer was also heard to engage in conversation with another service user when matters that should have been handled more discretely were talked about in a loud voice for all to hear. Just because the audience consisted in the main of people with learning disabilities does not mean to say that carers should treat information in a less than confidential manner. The home’s manager was informed immediately of the carer’s approach. An assurance was given that this would be discussed during the carer’s supervision. A previous requirement was made that the Registered Persons must provide the Commission with a statement of their policy and procedures involving the management of service users money that complies with latest guidance for corporate appointees. This was, in part, covered by an agreement between the Commission’s Provider Relationship Manager and Craegmoor. The separate financial accounts held at Head Office and belonging to service users were seen at this unannounced inspection. They did not show residents benefiting from interest payments despite some having considerable sums in credit. The manager had set up accounts with a local bank for all but one resident. These could be used for day to day spending and withdrawals could be made on demand. This is very much to their benefit and the manager must be commended for her action in this. The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 and 17. The offer of suitable day care arrangements to everybody living here would widen the circle of friends and acquaintances, fill the day with interesting things to do and potentially provide independent advocacy. A choice of dishes at the evening meal, including for vegetarians, would improve the quality of the dining experience. EVIDENCE: Following the last inspection, there was an exchange of correspondence in regard to the day care provided for a particular resident. The person concerned had been resident at the home for some years and had not been provided with any local authority, private or voluntary organisation day care services off site. When asked, the placing authority said that they had agreed a certain sum of money with The Oaks and Woodcroft for the provision of day care services. This appeared not to have happened and the resident expressed a wish during the last inspection to have day care provision. The matter was followed up during this visit and still no formal arrangements had been made for the resident. There are particular circumstances that make it quite important for the resident concerned to have outside contacts and access to a wider circle of friends and acquaintances. This matter must be resolved. The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 14 The mealtime arrangements were observed in one bungalow. The food looked appetising and nutritious. The home did not have the services of a cook and staff had to undertake catering duties as well as their caring tasks. In these circumstances, a real choice of dishes was not possible and, when asked, a member of staff said that if somebody were, say, a vegetarian, they would simply not have the meat component of the meal. It should be possible to offer a real choice, including for vegetarians, at what is for some residents their main meal of the day. The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None on this occasion. EVIDENCE: The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The manager’s efforts in making the service users’ Complaints Procedure available in more than one format is a real improvement. The company’s failure for nearly a year to ensure that all staff had POVA training has the potential to diminish the protection under which residents are living. EVIDENCE: The Commission received an anonymous letter raising concerns about staffing levels, management, low morale among staff, lack of supervisions and lack of stimulation or attention among residents. These matters were all looked into during this inspection. The findings have been mentioned elsewhere in the report under the standards and outcomes for residents to which they relate. The manager must be commended for making a start to provide the Complaints Procedure for residents in formats other than just written. This is a real improvement. But, again, she had been left to her own devices to come up with an alternative way to present the information. No assistance appears to have been forthcoming from the company where, presumably, resources were available for producing the information in a variety of different formats. A requirement had been made following two previous inspections that all staff must have training in the Protection of Vulnerable Adults (POVA). The original timescale for compliance of 30th April 2005 was extended to 30th September this year. The training matrix showed that of the 23 staff employed, 13 had had this important training. In particular, none of the Night Support Workers or Bank Staff shown on the training statistics had been POVA trained. The The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 17 Deputy Manager said that another POVA course is booked for February 2006 to ‘pick up the remainder of staff who had not to date been trained’ in this important aspect of care. The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 18 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): 25, 27 and 29. Residents are likely to find the setting generally very pleasant. Attention to some aspects of the physical environment would further improve the residential experience. EVIDENCE: Both bungalows were pleasantly decorated. In communal areas, such as the lounges, they were very homely and domestic in character. Residents’ bedrooms were personalised to a high degree to reflect their owners’ interests and activities. Being on one level, the accommodation is especially suitable for people with mobility difficulties. One bedroom in Woodcroft was extremely hot. Staff said that the bungalow had under-floor heating that had been giving some problems recently. It had been turned down to ‘low’, and this had an effect in the other rooms, but not in the one that remained almost unbearably hot. The air temperature was measured at almost 90oF. Heat could be felt radiating up from the carpet. The staff said that in normal circumstances opening windows controlled the heat. This seemed to be a particularly wasteful way of regulating the temperature of The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 19 the house and some attention should be paid to the system to ensure more controllable heat and to provide a more comfortable atmosphere. This was mentioned to the manager at an exit meeting and she said she would attend to it immediately. Currently, those living in Woodcroft have only one bathroom and while this complies with the National Minimum Standards, it does not allow any choice in the way people want to bathe – shower or bath. A good practice recommendation was made following the last inspection that when circumstances permit, the Registered Persons should consider installing an additional shower room in Woodcroft. This would reflect provision in The Oaks and would be of benefit to the people living in the house. This good practice recommendation has been repeated. Similarly, a recommendation was made last time that an interested member of staff should be encouraged to take responsibility for developing the Sensory Room. This space could be a real asset to the home if developed in a suitable way. Nothing appeared to have been done since the last inspection to change things. The room was still being used for a variety of purposes – storage, arts and crafts, a place for the musical organ etc. The expertise must exist within the company to develop this room to provide a range of sensory experiences that all of the people who live and work in the home would enjoy and derive benefit from. The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 20 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, 35 and 36. There are some worrying omissions here that both at a corporate level and inhouse might lower staff morale and diminish their ability to deliver the best care possible. EVIDENCE: The home’s training statistics showed that as far as assessment at NVQ is concerned, among the staff, the Manager has a level 4 and is working towards a Registered Manager’s Award, the Deputy Manager has a level 2 and one other carer is working towards a level 2. This comes nowhere near the National Minimum Standard that states care staff should hold a care NVQ 2 or 3, are working to obtain one by an agreed date or the manager can demonstrate that through past work experience staff meet that standard. 50 of care staff should have achieved a care NVQ 2 by the end of 2005. The anonymous letter sent to the commission raised concerns about low staffing levels even though some people living in the home had been assessed as at times needing 2:1 assistance. At the time of the unannounced inspection there were only three care staff on duty, divided between both bungalows. The Deputy Manager had gone out to pick up residents from day care, but was soon returned. But, this would only give two staff on shift in each bungalow. The Manager said that her baseline staffing level was 3 in each house. Her duties, she said, divide about 80 to 20 between management and ‘handson care’ and her job description states that she works mainly ‘office hours’ The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 21 during weekdays. Her Deputy is, he felt, ‘on the floor up to 75 of the time’. He works shifts, including at weekends. The manager was asked about staff meetings. The Minutes Book showed that staff meetings had been held on 9th February 2005 and 13th September 2005. This is not sufficient. Meetings to which all staff should attend should be held at least every two months. The manager said that two care staff had started work at the home at the beginning of October. In one case, the staff member had completed less than half the induction programme. The record showed that this had been covered all in one day. In the other case, no induction had been done. Bearing in mind that the National Minimum Standards state that induction training should be done within six weeks of appointment, and at the time of the visit both carers had been in post for over two months, this is not acceptable. The lack of timely and regular individual supervision sessions for staff was a matter of concern last time, and at three inspections before that. This had still not been satisfactorily resolved, although the manager said that senior staff had now been trained by Craegmoor Healthcare to supervise junior colleagues. She said that sessions would start soon. Bearing in mind that supervision training happened on 19th October 2005, the delay in staring the programme is worrying. The previous requirement that by 30th September 2005 all care staff must have training in challenging behaviour and physical control and restraint had not been met. The Deputy Manager said that four staff shown on the training matrix as not having done this training had in fact completed it very recently. There still remained 11 staff, however, including the manager, who had yet to do this training. None of the Night Support Workers or Bank Workers had received this training and bearing in mind that these staff would be working alone in one of the bungalows with no support from seniors immediate available, this is an oversight that must be resolved as a matter of urgency. The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 22 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): 42. A staff group fully trained in all aspects of health, safety and welfare of residents increases the potential for safe practice and in this case there are some improvements to be made. EVIDENCE: A requirement had been made previously that by 30th November 2005 all staff had training in aspects of care such as COSHH, fire safety, first-aid, health and safety and food hygiene. This had not been met. The training matrix showed the following. That out of 23 staff: • • • • • For COSHH - 12 had been trained, For fire safety – 13 staff had been trained First-aid - 8 staff had been trained H&S – 12 staff had been trained and Food hygiene - 10 staff had been trained. DS0000027492.V270452.R01.S.doc Version 5.0 Page 23 The Oaks / Woodcroft 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 1 3 1 X 1 Standard No 22 23 Score 1 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 1 X X 2 Standard No 24 25 26 27 28 29 30 STAFFING Score X 2 X 3 X 3 X LIFESTYLES Standard No Score 11 2 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 1 X 1 1 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Oaks / Woodcroft Score X X X X Standard No 37 38 39 40 41 42 43 Score X X X X X 1 X DS0000027492.V270452.R01.S.doc Version 5.0 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 YA1 Regulation 5(1) Requirement The Registered Persons must ensure that the Service Users Guide contains all the information in a form that service users have a chance of understanding. This requirement, to a varying extent, is outstanding from the previous four inspections. Following receipt of the draft report, Mary Preston, the company’s Operations Director, said that the Service User Guide had been worked on extensively and in the opinion of the staff was suitable for the clients. A survey was to be done to ensure the clients understood the format and the results would be sent to the Commission by 28th February 2006. If other formats were required, she said, these would be provided by the home. The Registered Manager must ensure that every resident has an assessment of his or her communication needs. This requirement is outstanding from the previous inspection. DS0000027492.V270452.R01.S.doc Timescale for action 30/11/05 2. YA3 14(1)(a) 30/11/05 The Oaks / Woodcroft Version 5.0 Page 25 3. YA5 5(1)(b)(c) 4. YA7 12(3) 5. YA7 20(1) Following receipt of the draft report, Ms Preston confirmed that the Community Team had been to assess the communication needs of the service users. Their comments would be transferred on to the Care Plans of each client. Ms Preston felt that because many of the service users had been resident for a number of years the staff had a good understanding of the client group. The Registered Persons must 30/11/05 ensure that each resident has a contract or terms and conditions of residence document in a format that they are likely to understand. This requirement was made under standard YA1 (as part of the S.U. Guide) in three previous inspections. The Registered Manager must 16/08/05 ensure that staff are able to communicate with every resident in an appropriate way so that they are able to make decisions about their day-to-day lives. This requirement is outstanding from the previous inspection. Following receipt of the draft report, Ms Preston confirmed that the home’s manager had sought the advice of a speech therapist and this advice would be transferred on to the Care Plans of the individual service users in question. The Registered Persons must 16/08/05 provide CSCI with a statement of their policy and procedures involving the management of service users money that shows, in particular, residents benefiting from interest payments on the money held for DS0000027492.V270452.R01.S.doc Version 5.0 Page 26 The Oaks / Woodcroft them. 6. YA10 The Registered Manager must ensure that at all times staff treat information on residents in a sensitive and confidential way. 14(2)(a)(b) The Registered Manager must 16(2)(m) set up suitable day care provision for service users that meets their needs. Following receipt of the draft report, Ms Preston said that the manager and senior staff were addressing this issue and were working hard to secure a placement for this particular service user to attend day care services. 16(2)(i) The Registered Manager must ensure that a real choice is offered at main meals and this includes for vegetarians. 22(2) The Registered Persons must provide the Complaints Procedure in a variety of formats that all service users are likely to understand. This links with a previous requirement, (see above in standard YA1), the timescale for completion for which was 30th April 2005. Following receipt of the draft report, Ms Preston said that the manager had been working with a qualified learning disability nurse from Craegmoor to develop a meaningful and understandable complaints procedure for service users at the home. 18(1)(c) (i) The Registered Persons must ensure that all staff have training in the protection of vulnerable adults. This was a previous requirement with a timescale for completion of 30th April 2005. 23(2)(p) The Registered Manager must ensure that service users’ bedrooms are only heated to a DS0000027492.V270452.R01.S.doc 12(4)(a) 01/12/05 7. YA11 31/01/06 8. YA17 31/12/05 9. YA22 30/11/05 10. YA23 30/09/05 11. YA25 01/12/05 The Oaks / Woodcroft Version 5.0 Page 27 12. YA32 13. YA33 14. YA33 15. YA35 16. YA35 17. YA36 temperature with which the occupant is comfortable. 18(1) The Registered Persons must 19(5)(b) provide the Commission with a statement of how they intend to achieve a ratio of 50 of care staff assessed at NVQ level 2 as soon as possible. 18(1)(a) The Registered Persons must ensure that sufficient numbers of care staff are on duty, on the floor, at all times. 12(5)(a) The Registered Manager must ensure that full staff meetings are held at least six times a year and minutes are taken. Arrangements must be made for all staff to attend. 18(1)(c) (i) The Registered Persons must ensure that all staff have training in challenging behaviour and physical control and restraint. This is a requirement repeated from the last inspection and with a timescale for completion of 30th September 2005. 18(1)(c)(i) The Registered Manager must ensure that all newly employed staff receive full induction into their posts within 6 weeks of talking up their appointments. Following receipt of the draft report, Ms Preston said that all staff had been issued with an induction pack and the manager and her senior colleagues would ensure that they are completed within the current six-week timescale. For the company’s information, the introduction of Common Induction Standards will change the timescale to 12 weeks. 18(2) The Registered Manager must ensure that staff have regular individual supervision at least every 8 weeks. The provision of DS0000027492.V270452.R01.S.doc 31/01/06 01/12/05 01/12/05 30/09/05 01/12/05 16/08/05 The Oaks / Woodcroft Version 5.0 Page 28 18. YA42 12(1)(a) formal supervision was linked to requirements made following four previous inspections. The Registered Persons must ensure that all staff have training in aspects of care such as COSHH, fire safety, first aid, health and safety and food hygiene. This requirement was previously made following the last inspection. The timescale for completion was 30th November 2005. Following receipt of the draft report, Ms Preston said that food hygiene training courses were provided ‘in-house’ and had commenced. 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA29 Good Practice Recommendations The Registered Manager should encourage an interested member of staff to take responsibility for developing the Sensory Room to provide a range of experiences for service users in this potentially tranquil atmosphere. The Registered Manager should in respect of supervision sessions, introduce a Supervision Log and individual Supervision Contracts for staff. Following receipt of the draft report, Ms Preston said that the manager would make arrangements as necessary. The Registered Persons should consider installing an additional shower room in Woodcroft. This would reflect provision in The Oaks and would be of benefit to the people living in the house. Following receipt of the draft report, Ms Preston said that at present it was not possible to install a shower in Woodcroft as it would mean the loss of a toilet. 2. YA36 3. YA27 The Oaks / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 / Woodcroft DS0000027492.V270452.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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