Inspection on 16/08/05 for The Oaks & Woodcroft

This inspection was carried out on 16th August 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 13 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 01/12/05

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 2a Dereham Road Mattishall Dereham NR20 3AA Lead Inspector David Welch Unannounced 16 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Oaks/Woodcroft Address 2a Dereham Road, Mattishall, Dereham, Norfolk, NR20 3AA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01362 855040 01362 858954 None Conquest Care Homes (Norfolk) Limited Mrs Karen Elizabeth Bash Care Home 12 Category(ies) of LD Learning disability registration, with number of places THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27 January 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 pesonalise, and there are shared lounges, dining room, 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 Craegmore Healthcare On the day of the inspection, the home had no vacancies. THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day in August. The visit lasted almost 8 hours. The manager, Karen Bash, was present throughout the day and her help with the inspection was greatly appreciated. During the visit, 3 care staff were interviewed in private, using a pre-prepared list of questions, with an emphasis on what it is like to work at this residential home. Four residents were spoken to at length, and most of the others who were either at home for the day or who arrived back during late afternoon were spoken to in passing. Two people were on holiday in Scotland with two carers. Case files, records, policies and procedures were available for inspection. Some documents were not to hand and the manager said she would forward them to the Commission as soon as possible and later did so. There was an opportunity to make a tour of the two bungalows at the beginning of the inspection. Topics discussed at the beginning of the day included the probable changes to the regulatory process due by 2008 and the new reporting format that, hopefully, will make this report more accessible to staff, service users and their supporters. The history of inspection at The Oaks and Woodcroft is that there were some nineteen requirements made at the last inspection, and five good practice recommendations. Eight of the requirements made in January 2005 had been outstanding for at least two previous inspections, nine from at least one inspection. All five recommendations that had been previously made had not been complied with. This inspection provided a chance to re-visit them to check what progress had been made. Sad to say, only a minority of outstanding requirements and recommendations had been satisfactorily dealt with by the home. These matters are now urgent and because previous requirements have not been met the home has been ‘flagged’ as being of concern to the Commission. While the Registered Manager is responsible for some unmet standards, Craegmoor, the owners, must shoulder the responsibility for ensuring that many of the unmet standards are put right. The manager cannot have an influence on things that are corporately decided. With the above in mind, an announced inspection is planned for later in this inspection year, i.e. before 31st March 2006, but additional unannounced visits might also take place in order to check progress on compliance. Having said that, staff were generally upbeat about working at the home and residents were happy and spoke positively about living here. THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 6 A copy of the home’s Statement of Purpose and Service User Guide was available, but time did not permit a thorough examination of these two documents, which was left until later. What the service does well: What has improved since the last inspection? What they could do better: A majority of outstanding requirements and good practice recommendations, previously made, remain to be done. This will have an effect on the way that over the next twelve months the Commission views the home and the THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 7 regulatory activity that results. The parent company must ensure that it takes responsibility for things that are ‘corporate’, such as the setting up of suitable financial arrangements for service users, staff training, providing the facilities to produce documentation in different formats and staffing levels at times of ‘shortage’. It must monitor the way the home is managed, progresses and develops. The manager must ensure that Care Plans contain all the information required by staff to assist service users in the most appropriate ways. This includes having guidance for any challenges that service users might present. Every resident must have an assessment of their communication needs so staff can be sure that they are using the most suitable method to communicate with the people they are assisting. Staff must have regular and timely supervision. The suitability of one person’s placement in Woodcroft should be looked at. The Commission has written to the Learning Disabilities Team concerned to ask about social worker allocations and day care provision. 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 I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 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 standard(s) 1, 3 and 5. The Commission is not convinced that at present the residents have all the information required. In particular, the Complaints Procedure and a terms and conditions of residence document for residents is lacking. With people who might not have sufficient language or literacy skills, it is important that staff are armed with the information required to communicate in the most effective ways and this is not always the case at this home. The format in which the residents’ contracts are provided disadvantages them. EVIDENCE: Following the visit, the Statement of Purpose was examined and, in its written form, included all of the information required under Schedule 1 of the Care Homes Regulations 2001. But, staff confirmed that all of the people living at the home would have difficulty reading the written word so the Statement of Purpose in this form would not be accessible to them. The manager had made efforts to produce the Service User Guide in an alternative format using ‘Widget’, a pictorial system that translates written words into a line of ‘typed’ symbols. The document is closely ‘written’, however, and only those quite able residents used to this form of communication would be able to understand the messages being given. Staff said that this was not a form of communication widely used throughout the THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 10 home. A member of staff had been identified to take a lead on ‘communications’. She had attended a two-week course with the Learning Disability Team and had produced some Makaton signs for staff. These had been copied and were available in the staff room in The Oaks. One carer referred to them during interview when asked about methods of communication with residents. As only one resident has limited Makaton, however, it must be concluded that the home’s documentation as it stands is not in formats that all residents are likely to understand. The terms and conditions of residence document was seen and this, too, was in the form of a typed ‘contract’ and as such not accessible to the people living at The Oaks or Woodcroft. While there was a Complaints Procedure, this, too, was not in a format likely to be understood by all residents. The possibility of using video, audio, DVD, ‘key rings’ etc was discussed and with the resources available to the parent company the provision of this documentation in appropriate formats must be taken seriously. There had been some attempt to provide photographs of people working in the home. These were displayed in the main entrance to The Oaks. There was no other evidence of communication aids displayed for residents such as pictorial timetables, places of interest, or meal choices in the kitchen. When asked about the ways that residents could make their wishes known, say about what they wanted to wear, and especially in relation to those residents seen to have little language and perhaps limited understanding, one member of staff simply said that they chose the garment for the person concerned. This is not the best care practice and even the people with the most profound of communication difficulties are likely to be able to indicate their preferences in some way if experienced staff pick up the cues and clues available. THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 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 standard(s) 6, 7 and 9. There was sufficiently good evidence that residents are able to make some of the decisions relevant to their day-to-day living. A start has been made, but some work remains, to ensure that staff are armed with all the information required for them to be confident they are able to communicate as effectively as possible with everybody living in the home. More details will be required in Care Plans to ensure that staff have all the necessary information. The independence of service users is enhanced by them being able to take some considered risks. EVIDENCE: Records for each of the twelve residents were looked at and the dates of the last statutory review of their care checked. In The Oaks, all six residents had had a review within the last eight months. In Woodcroft, four people had had a review within the last 11 months. Only four people had the date of their next statutory review booked. These arrangements did not conform to what the home’s Statement of Purpose says, which is that people are reviewed every six months. The manager said that in one or two cases, residents did not have social workers allocated to them and this might be the reason for THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 12 review dates not yet being agreed. The Commission has written to the Social Care Services in respect of one person who was said not to have a social worker. One of the previous requirements was that there must be guidance for staff in Care Plans in dealing with challenging behaviour presented by residents. One person, in particular, was said to be ‘challenging’. This manifested itself in inappropriate urination and refusal to take medication unless ‘disguised’. The person concerned also presented a physical challenge at times to staff. Some of these challenges were not recorded and the manager could not locate guidance for staff in dealing suitably with all of them. The case file for the person concerned had some potentially useful and informative sections included under the ‘Me’ details. These included, ‘Some good things people say about me’, ‘Some things that are essential to me’ and ‘To support me along my Pathway, friends must be aware that’. Unfortunately, these pages were blank. No information had been recorded. The home had made the effort to identify these headings as important in the first place, but it detracts from the information that staff should have, and that is necessary to meet the individual’s needs, if they are not filled in. A timetable was in symbol form. Another previous requirement was that residents must have an assessment of their communication needs. When this was again discussed, the manger produced a letter from the Learning Disabilities Team confirming that they knew residents and their needs had been assessed and reviewed. Nothing appeared on individual Care Plans, however, and there seemed not to have been individual assessments carried out. This is now urgent and must be done. The financial arrangements were again looked at. It seemed that the system remains that service users’ ‘benefits’ are paid directly in to Craegmoor’s accounts, but the home’s manager now has a bank card so that she can withdraw money to cover individual personal allowances. Each person also has a Savings Account at the local bank. This latter is good practice, but the fact that cash in the first instance is going in to the company’s account is not in line with good practice guidelines and should stop. Craegmoor has, it is understood, confirmed that it is working on a different arrangement, but this is not yet in place. The sooner this happens the better. Until it does, the home will not comply with National Minimum Standards and requirements will remain. The risks that residents take have been individually considered and actions taken to minimise them. It was not possible to check whether an assessment had been made of the use of bed rails for one person, as the Care Plan, sensibly, had been taken on holiday with him and the staff. THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 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 standard(s) 12 and 14 The busyness and involvement of residents in the variety of activities and outings provides an improved quality of life for them here. EVIDENCE: Several residents were out during the day at various day care and education sessions. Residents were clear that one of the best things about the home were the activities. During the day, residents were seen to be involved in activities suitable for their age and personal inclination. One person went off with a member of staff to look at trains, while others went on outings. One person was engaged in playing a keyboard. The atmosphere was ‘busy’, but relaxed, with no sense of hurry and rush. One resident watched a favourite video on television. One person interviewed confirmed that they had no day care activities arranged and the Commission has written under separate cover to the social work team concerned to enquire about this. One thing did concern the Commission. The home’s manager said that a day care venue for a couple of residents, where they were happy and settled, had THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 14 been arbitrarily changed at very short notice by the Social Care Services for no apparent reason and without any consultation. This seems a particularly insensitive way to proceed. THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 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 standard(s) 20. While the administration of medication was not looked at in depth, on the evidence that was available, the Commission feels that residents are suitably cared for in this respect. EVIDENCE: A previous requirement said that the home must have appropriate recording arrangements for ‘home remedies’ such as ‘off-the-shelf’ pain killers, head ache tablets, linctus, throat pastilles and the like. This was again looked into and the inspection found that service users had a separate ‘home remedies’ guidance sheet for staff. Any home remedies were listed on case files. The home used a monitored dosage system based on the Boots procedures. The local GP surgery is close by and very convenient. On three occasions during the day, staff took residents to the surgery for minor ailments and got rapid service. It was clearly a very useful arrangement. Medication Administration records (MAR sheets) were not examined on this occasion. THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 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 standard(s) 22 and 23. If Complaints Procedures are not accessible to the people living in the home in a format that each of them can understand, their right to make any unhappiness or dissatisfaction known will be limited. It is important that all staff have training in protecting the vulnerable people living here and this is especially the case when carers are working at night with the usual supports not immediately on hand. EVIDENCE: A previous recommendation was that the complaints procedure should be produced in a format that is suitable for all service users. This had not been done and will now be a requirement that must be complied with as a matter of urgency. The manager said that all staff had undertaken Protection of Vulnerable Adults (POVA) training. Training records were not accessible at the time of the inspection, but she agreed to forward a training matrix to the Commission later on. They showed that of the 25 staff, including Bank Support Workers, only 16 had had POVA training. Worryingly, none of the night carers had been Adult abuse/POVA trained. THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 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 standard(s) 24, 26, 27, 29 and 30. While the two houses together appear large and the layout could be said to have some ‘institutional characteristics’, such as long corridors, an internal bathroom and a reception area, in other ways every effort has been made to provide a safe, secure, homely and domestic atmosphere and this is to be welcomed. The personalisation of individual bedrooms allows each resident the freedom to create their own space as they want and they are delightful. The privacy of bathrooms and toilets is not an issue while adaptations have been made to satisfactorily accommodate the people living at the home. The home was overwhelmingly clean and hygienic, but, in places, some residual odour problems detracted from staff efforts to keep the home fresh smelling. The lack of development and obvious use of the ‘Soft Room’ was disappointing, as this can provide a truly sensory experience for people whose ability to communicate in other ways might be limited. EVIDENCE: THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 18 The hanging baskets and flower tubs around the two buildings provided a bright and colourful display. It gave the place a really cheerful look. The swinging garden furniture was popular and on the day of the inspection, which was warm and sunny, was being put to good use by the people living and working in the home. The garden is safe with a secure perimeter fence. The carpet in The Oaks corridor had been replaced and new flooring had been laid in the Woodcroft bathroom. Locks had not been provided on all bedroom doors as not all service users would be able to use a key and therefore access to their own room would be limited. There are plans to replace the carpet in The Oaks lounge. Residents’ bedrooms showed every sign of being personalised with soft toys, ornaments, posters, pictures and photographs. Some people had their trophies and certificates displayed. Others had their collections on show. Toilets and bathrooms were sufficiently private. While under revised National Minimum Standards the Commission cannot require an additional bathroom in Woodcroft, for a group of six people with learning disabilities, one is hardly sufficient, and a recommendation has been made that a shower room is fitted there. One resident used a ‘Profile’ bed, with bed rails. The home had a hoist with suitable slings. Where necessary, wheelchairs were in use. In The Oaks there was a ‘soft room’/Snoozalum. Unfortunately, this had become more an all-purpose activity room with a desk and keyboard and a counter where arts and crafts could be done. Sensory rooms can be extremely useful aids to care delivery and it is a pity that the use to which this room has been put has become ‘blurred’. Some residents derive a great deal of pleasure and comfort from experiencing sensory effects and an interested and experienced member of staff should take this over and develop it to its full potential for the benefit of the people living in the home. In places there was some unpleasant odour. Each house had a laundry. All washing was done on the premises. Staff were seen to wear disposable gloves and aprons. THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 and 36. Although CRB checks in respect of one person remain outstanding, the Commission are reasonably sure that recruitment checks are sufficiently robust for the rest of the staff group. It was pleasing to note that induction training had been given a suitably high priority by the company. Some concern does, however, exist in the extent and range of further training provided. Important aspects have been missed out or delayed for some carers, which have the potential to develop staff personally and will certainly protect the vulnerable people living here. Individual supervision remains ‘patchy’. EVIDENCE: The details of staff CRB disclosures were not available on the day of the inspection, but the certificate numbers for twenty staff were forwarded to the Commission shortly afterwards. We had also asked for the dates that all staff started their employment at the home, and the dates of their CRB certificates, to be forwarded. At the time of writing, full details for all but one staff member had been sent to the Commission. The details for this person remain outstanding. This was discussed with the manager in a telephone call to the home on 26th August 2005. THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 20 Everybody had completed the company’s induction training, but only 2 had finished their foundation training that should take place within 6 months of taking up their appointment at the home. Nobody had done equal opportunities awareness training. Only 16 staff (65 ) had POVA training. And only seven (28 ) had done challenging behaviour and physical control and restraint training. Bearing in mind the vulnerability of the people concerned and the challenge that some present, all staff must be sufficiently well trained to meet the needs of the service users. The staff who were interviewed had varying experiences of individual supervision. Some reported that supervision had taken pla e every 6 to 8 weeks, while others said that it was not as frequent or as regular as they would like it to be. When the matter was discussed with the manager, she said that she had been trained in supervision on 31st May this year, but her senior colleagues had yet to complete training in supervision techniques and the burden for all supervision at present fell on her, which was quite onerous. It is a full-time job supervising all 25 staff appropriately and other senior colleagues must be trained as quickly as possible to bear some share of this. It has been recommended that the manger keeps a Supervision Log and each member of staff has a Supervision Contract that sets out location, frequency and the topics to be covered during the sessions. One member of staff said that at times staffing could be short. This was apparent on the day of the inspection when a small number of staff were involved in an in-house training session. This left only two staff to cope on their own with some people who needed a lot of help. THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42. Only when all the people working in the home are fully trained in every aspect of safety awareness can the company, and the Commission, be sure that everything has been done to protect residents and staff from accident. EVIDENCE: The 3 staff interviewed confirmed they had had training in first-aid and health and safety. Over half the staff had COHSS training. Thirteen had been trained in moving and handling and fifteen in fire safety. All staff must have this important training in order to protect the people living in the home. On the day of this unannounced inspection, a few staff were involved in infection control training with more due to do it the following week. THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 22 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 2 x 2 x 2 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 3 x 3 3 Standard No 11 12 13 14 15 16 17 x 3 x 3 x x x Standard No 31 32 33 34 35 36 Score x x x 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 THE OAKS/WOODCROFT Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 23 No 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 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 three inspections. The Registered Manager must ensure that every resident has an assessment of their communication needs. The Registered Persons must 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 two previous inspections. The Registered Manager must ensure that all the information relating to challenges that service users are likely to present are recorded in Care Plans to ensure staff have the necessary guidance. This requirement is outstanding from three previous inspections and a Timescale for action 30th November 2005 2. YA3 14(1)(a) 30th November 2005 30th November 2005 3. YA5 5(1)(b)(c) 4. YA6 15(2)(b) Immediate. THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 24 5. YA7 12(3) 6. YA7 20(1) 7. YA22 22(2) 8. YA23 18(1)(c) (i) 9. YA35 18(1)(c) (i) 18(2) 10. YA36 11. YA42 12(1)(a) timescale for compliance was last given as 30th April 2005. This matter is now urgent. The Registered Manager must ensure that staff are able to communicate in an appropriate way with every resident so that they are able to make decisions about their day-to-day lives, for instance what clothing they want to wear. The Registered Persons must provide CSCI with a statement of their policy and procedures involving the management of service users money that complies with latest gudiacne for Corporate appointees. 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. 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. The Registered Persons must ensure that all staff have training in challenging behviour and physical control and restraint. The Registered Manager must ensure that staff have regular individual supervision at least every 8 weeks. The provision of formal supervision was linked to requirements made following three previous inspections and is now urgent. The Registered Persons must ensure that all staff have training in aspects of care such as Immediate. Immediate 30th November 2005. 30th September 2005 30th September 2005. Immediate and ongoing. 30th November 2005. Page 25 THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 COSHH, fire safety, first aid, health and safety and food hygiene. 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. 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. 2. 3. YA36 YA27 THE OAKS/WOODCROFT I55 s The Oaks Woodcroft V244623 160805 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 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. 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