Inspection on 16/05/06 for The Oaks & Woodcroft

This inspection was carried out on 16th May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 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 01/12/05

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 id Welch Unannounced Inspection 16th May 2006 03:00 The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 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 www.craegmoor.co.uk 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.V295603.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 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 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. 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. On the day of the inspection, the home had no vacancies. Fees range from £755.00 to £1148.00 per week. This information was provided by the home in a pre-inspection questionnaire, which was returned to the Commission on 18th April 2006. Inspection reports are available on request from the home. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place unannounced from mid afternoon to the evening and was timed so that it would be possible to speak to residents after they had returned from their day care, were having their cooked meal and, maybe, doing some activities later on. Seven residents were spoken with during the course of the visit. Four carers were on shift at various times and they, too, were all spoken with as they went about their duties. The manager was available for the majority of the visit and she was a great help. Two relatives were visiting at the time of the site visit and they, also, were spoken with. There were some very positive comments about the home and the care given. The Commission met with the parent company’s Operations Director in January this year in order to discuss various concerns it had about the home. Afterwards, an Action Plan was provided that showed how the outstanding requirements and recommendations would be dealt with. However, what the Operations Director said in her letter to the Commission did not always tally with what she had agreed with the home’s manager, who was left in the dark in several vital areas about what had been promised on her behalf. A subsequent additional visit to the home showed that improvements had been made and there seemed to be a new vitality to the atmosphere. Prior to this site visit, comment cards were left for residents and their relatives to complete and return if they wished. In the event, three comment cards were returned to the Commission from people living in the home, all of whom had some help with filling them in. Six comment cards were returned by relatives. Overwhelmingly, the feedback was very positive. Mrs Bash sent the Commission some information prior to the site visit. This included a training matrix and supervision programme. Afterwards, she very helpfully faxed some further details about review dates, personal support and healthcare, education/work experience, day care activities, community links, family contacts and leisure pastimes. What the service does well: The home has hung on to the good things, which included • • • • • Level access to the two bungalows so that people with mobility difficulties are not disadvantaged. The safety of the surroundings, set back from the road, and the quiet village setting There is a secure garden. The houses are nicely decorated and well fitted. The communal spaces, in particular, are pleasant places to spend time. DS0000027492.V295603.R01.S.doc Version 5.2 Page 6 The Oaks / Woodcroft • • • Residents can personalise their bedrooms to reflect their interests and characters. There are warm relationships between some staff and residents. The manager’s action in securing separate, local bank accounts for residents is of real benefit and the fact that people living at The Oaks and Woodcroft have them is an example of anti-discriminatory practice in action for which the management should be commended. Each resident has been issued with a Service User Guide that is signed either by themselves or by a relative. The quality and choice of meals is good. In general, most residents have busy and active lives, with choices of day-time activities. Family contacts are encouraged and there appears to be friendly working relationships between staff and visiting relatives. The is good healthcare and personal support for residents. In most respects the medication administration is done well. The Regulation 26 visits are taking place regularly and reports are being produced to time. What has improved since the last inspection? What they could do better: The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 7 Residents’ reviews should be held at more regular intervals. The company’s procedures for dealing with residents’ money should be brought into line with agreed guidance. There should be a stimulating and interesting evening programme of activities for residents, if they wish. The staffing arrangements in the evenings are not helpful to the introduction of a varied programme of evening activities. Residents should be offered the chance of an annual health check. Staff should be encouraged to go forward from induction to foundation training. The programme of individual supervision sessions, and the recording that goes with it, should work far more smoothly. The innovative and helpful work that individual carers are doing with residents should be shared between staff and coordinated. 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.V295603.R01.S.doc Version 5.2 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.V295603.R01.S.doc Version 5.2 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. The quality in this outcome area is felt by the Commission to be good. It was clear that a great deal of time and effort had been put into new, and different, methods of communicating with residents. Staff appear to have been thinking much more deeply about ways of improving their practice in this area. EVIDENCE: The Statement of Purpose now contains all the required information. There had been some misunderstanding, the manager said, about the expectations on her by the company’s Operations Director to carry out a survey of residents to find out if they understood the format of the Service User Guide, with the results being sent to the Commission by 28th February 2006. If other formats were required, the Operations Director said, these would be provided by the home. During this site visit the matter was again discussed and the manager said that the Service User Guide still needs some more work as she feels that photographs are more useful than signs or ‘Widget’ symbols. It was clear that each resident now has a copy of the Service User Guide that includes the terms and conditions of residence document in formats other than just the written word. Some significant progress has been made in this area. The Commission was able to give some advice during the preparation of the document so that more ‘plain English’ was used. This had been adopted. A The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 10 relative had signed each Service User Guide and terms and conditions document, where appropriate. The Care Plans of four residents, chosen at random, were checked. Each person had had a communication assessment and a ‘communication profile’ is now included on each person’s Care Plan. Some were lacking in detail and in conversation with one carer it was clear that she was doing some very good work with a particular resident around developing and recording what was his level of communication. But this was somewhat in isolation and advice was given about sharing this with other staff so that it could be further developed and a consistent approach taken. There has been some training for staff by Wymondham Health Authority on communication skills and the communication worker from another Craegmoor home has also been in to assist the process. The Manager has purchased a Dictaphone and a member of staff has been identified (sadly on sick leave) to work on developing audio formats for important documents. Menu and Activities Books, in picture and photograph formats, were in the process of being developed. Staff said how they thought they would be able to use these to encourage residents to choose. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 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, 8 and 9. The quality in this outcome area is felt by the Commission to be adequate. Care Plans are sufficient so that residents can be confident that their needs will be met. But, the long intervals, in some cases, between reviews, when all concerned are present, could lead to consideration of the residents’ all-round needs not being discussed as often as they should, which could be to their disadvantage. While the home’s own arrangements in relation to individuals’ money are very good, the company appears to be dragging its feet in implementing a system whereby residents can have immediate access to their own money which is being held centrally. Consultation with residents is good and any risks they take are considered in a suitable way. EVIDENCE: Information provided by the manager showed that each resident’s needs had been reviewed. In six cases this was within that last 6 months or slightly over. Three people had had a review in the last year or so. Two people last had The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 12 reviews at the beginning of 2005, but in one case not since September 2004, some 20 months ago. Only 4 people had reviews planned, and these were to take place this month. The reviews of the other 8 residents were ‘to be arranged’. The residents continued to have local bank or building society accounts and, of course, could access this cash immediately. But, although the manager said that the company keeps residents’ cash centrally in separate accounts, it has still not introduced a system whereby each person is able to have immediate access to his or her money. In some cases, Craegmoor is keeping some quite large sums centrally in these accounts. The manager was somewhat surprised that the Regulation 26 visitors had both said that resident meetings were not being held at present as they had one in March. Another was planned for later this month. She should take this up with the people concerned. The manager confirmed that nobody has gone missing in the last 12 months. Two people do what for them are quite risky things such as boiling a kettle and frying eggs. These risks have been thought about and staff are always on hand. The kitchen is locked if staff are not around. Knife drawers are locked. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 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, 12, 13, 14, 15, 16 and 17. The quality in this outcome area is felt by the Commission to be adequate. Generally, most residents lead active and busy lives during the day, according to their needs and wishes, but efforts must continue to secure suitable day care for one person, in particular. The evening routines might not provide as stimulating or as interesting a variety of activities as possible, maybe as a result of the staffing arrangements. Meal quality and choice is good, offering nutritious and balanced food. EVIDENCE: In the Action Plan sent to the Commission after the last inspection, the Operations Director said that the home’s staff were working hard to secure a placement for one service user, in particular, to attend day care services and that this would be settled by 28th February 2006. The matter was again discussed during this visit, when the manager said she had written to the Learning Disability Team concerned, but that there had been no progress as yet. This matter is urgent as the weekly programme of the service user shows her remaining at The Oaks and Woodcroft for most of the week. One other The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 14 person does not have day care and in one case it was ‘under review’. The majority of the other residents have regular day care or education/work experience consisting of between 2 and 5 days a week. All but 4 of the people living here (because of mobility difficulties or from inclination) engaged in some simple household chores. All but one person had contacts with family and/or friends ranging from ‘occasional visits’ to daily contact. Some people said that they go and stay with relatives. One person was looking forward to staying with his sister. He said that staff take him and bring him back. While details provided by the manager of community links for residents showed that many of them do go to the pub, to shops, restaurants and the theatre, at no time in the 4 visits made to the home has there been much activity during the evenings. Although, during the ‘additional visit’ in January two people had gone out to a football in the community session. Two relatives felt that there was not always sufficient staff on duty. One member of staff on the day of this site visit said that staffing arrangements during the evenings are ‘thin’. It means that there are unlikely to be staff available to take residents out and in any case ‘day staff’ finish shift at 8.00pm. Also, when two staff are assisting one resident with personal care prior to bed the other 5 residents are left without supervision. This matter will be referred to more fully later in this report. The manager confirmed that no resident is on a special diet such as that required, say, by diabetes although one person does not eat a particular meat product. The inspection took place at a time when some residents were eating their cooked evening meal. All but one person in Woodcroft had opted for the 2nd choice – cheese and potato pie, freshly cooked - rather than the 1st choice which was chicken. On person had sausages. As it was somebody’s birthday the dessert was birthday cake complete with candle! Everybody, including staff, had a piece. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 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): 18, 19 and 20. The quality in this outcome area is felt by the Commission to be good. Residents are supported, with the personal care and health care needs of residents being well met. Medication administration arrangements generally support and protect residents, but the home should guard against isolated examples of poor practice at times, which could put residents at a disadvantage. EVIDENCE: The manager provided details of each resident’s personal and healthcare needs. The times of getting up and going to bed were noted and if individual residents needed assistance with such things as washing and/or shaving. The two people who need the hoist to bathe were named. Another person who at first acquaintance appears to need help with mobility is actually quite able to get around the home. Everybody was identified as needing help at some level. The dates on which people had hospital appointments, with the dentist, optician and chiropodist were also noted. Three people have a Community Psychiatric Nurse and nine have access to the services of a ‘specialist nurse’. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 16 Only one person has had an annual health check and the manager reported that in the cases of everybody else these were ‘to be arranged’. Two people have significant mobility difficulties, including one person who is becoming very physically frail. Both need a hoist at times. The appropriate technical aid was available and staff knew how to use it. The Medication Administration Record (MAR) sheets were looked at. Everything was in order, including details of any ‘home remedies’ given. The home uses a monitored dosage system for medication. Recently staff noticed that one particular medication seemed to be reacting to another in the ‘blister packs’ and suitable steps were taken to remedy this. The local pharmacy that makes up the blister packs is just across the road and the arrangement is one that is very convenient for those living at The Oaks and Woodcroft. Staff were seen to be using the correct code if a resident did not, for any reason, take medication on any particular day. One matter of concern was that in one of the houses the 5.00pm medication was given almost two and a half hours late. While probably not too much of a problem, this meant that night medication would also have to be given later. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 17 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 quality in this outcome area is felt by the Commission to be good. The introduction in different formats of complaints procedures for residents will have improved the potential for their understanding in this area. While the inclusion of staff in POVA training will have further protected residents from abuse, neglect and self-harm. EVIDENCE: The Complaints Procedure is included in the Service User Guide that each resident has, and is in symbol and sign format. The manager confirmed from training records that all the staff except the Gardener, and a bank worker currently at university, had been trained in the protection of vulnerable adults. Clearly, a good deal of progress has been made in this respect. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 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): 24, 25 and 30 The quality in this outcome area is felt by the Commission to be good. The home is very suitable for its stated purpose and the installation of the ramp will improve matters further for those people living in The Oaks. It is unfortunate that the provision of a shower room in Woodcroft cannot be made without losing other facilities. EVIDENCE: At the time of the visit the Maintenance Person was working on the shuttering for the ramp. He showed how this would fit and said that he intended to install a plastic sheet so that the threshold from the Dining Room into the garden was not a tripping hazard. The manager said that the heating thermostat had been replaced in the resident’s bedroom where, previously, there had been a problem. The room was checked and found to be at a reasonable and quite comfortable temperature. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 19 The laundry has an industrial style washing machine and tumble dryer that certainly look up to the job in hand. Washing powder is added automatically in metered quantities. The machine has a sluice cycle and what appears to be adequate drainage with a ‘U’ bend so that foul water is not siphoned back. The waste goes into the foul sewer. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 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. The quality in this outcome area is felt by the Commission to be poor. While the involvement of more than half the care staff in NVQ assessment will ensure a confident and competent work force, this is undermined by the lack of foundation training. While carers are both caring and considerate, the staffing arrangements in the evenings detracts from the range of activities of offer, leading to a poorer quality service for residents. The lack of evidence that supervision sessions are now being held regularly, and at the required intervals, is worrying, as many care practice issues, problems and difficulties can be resolved in these face-to-face meetings. EVIDENCE: The training matrix showed that only a couple of staff had NVQ2, but more than 50 of care staff were ‘working towards’ it. This is sufficient and the Commission acknowledges that good efforts have been made in this regard. While there were sufficient numbers of staff on shift at 3.00pm, and then when people were returning from day care and other trips, including shopping for clothes, the number of carers in each house later on reduced to only two. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 21 There appeared not to be any efforts at providing a stimulating environment for residents during the evenings. While staff clearly had very good relationships with residents and engaged them with warmth and affection, there were no activities other than washing up after the evening meal and beginning the process of getting ready for bed in some cases. Some residents were simply roaming around the corridors or sitting watching t.v. The number of staff on shift did not allow for residents to, say, go to the pub or out for a walk or to do an activity with staff support. The shift pattern, with the day shift finishing at 8.00pm, similarly, allows very little time for outings before night staff take over. This is especially unfortunate at this time of year when the nights do not draw in until almost 9.30pm. Staff in one house said that with the number of colleagues on shift, and with one resident needing two carers when getting ready for bed, the five other residents, some of whom are very vulnerable indeed, could for a time be without direct supervision or oversight. The manager confirmed that foundation training has ‘got lost’. It is clear that a number of staff are quite mature people and the manager suggested that not everybody is confident about training, although ‘they are brilliant carers’. The new Common Induction Standards (CIS) for care staff in homes for adults might go some way to solving this problem in that they are designed to be completed within a maximum of 12 weeks. They take the place of induction within 6 weeks of taking up appointment and foundation training that should be completed within 6 months. It might be helpful if the company arranged some training for those less confident staff members, who while being very capable practical carers, feel they have little to offer when reports are required. Or, who find it difficult to contribute formally to records and generally are apprehensive about ‘written work’. Very helpfully, the Commission were provided with a supervision log prior to the site visit. This showed a programme of individual supervision sessions for staff throughout the year at intervals of about 5 to 8 weeks in most cases. Four staff were selected at random on the day of the visit and their supervision was checked. In all, between them, 13 sessions had been planned from January 10th to May 9th. Records showed that in only 3 cases was evidence available to say that the supervisions had actually taken place. The manager said that she had certainly had supervision with her supervisees, but the notes had not been written up. In the case of one supervisor, some problems about content had led to sessions not taking place and in the case of another supervisor sick leave had intervened. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 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): 39 and 42. The quality in this outcome area is felt by the Commission to be good. The monthly Regulation 26 visits provide a welcome additional level of oversight that, used properly, will continue to improve services for residents. The health, safety and welfare of residents was being promoted well. EVIDENCE: The ramp was in the process of being constructed at the time of the visit. While level access was provided to the rear of Woodcroft at the time the house was built, no such facility was provided for The Oaks. This puts residents of that house at a disadvantage especially as they have the greater need, as their mobility is generally poorer. Hopefully, the new ramp will provide safer access to the garden and to the other house. The manager said that there had been a resident’s meeting in March and another was planned for later this month. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 23 There remained only one person who had not completed H & S training and she was on maternity leave. The Accident Book and Fire Log were up to date, with checks recorded. The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 X 5 3 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 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 1 3 3 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15(2)(b)(c) Requirement Timescale for action 31/05/06 2. YA7 3. YA11 The Registered Manager must ensure that residents have a review of their care, to include all relevant people, at least every six months. 31/05/06 20(1) 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 guidance for Corporate appointees. Following receipt of the draft report of the inspection in December 2005, Ms Preston, the then Operations Director for Craegmoor, said that this statement would follow by 31st January 2006. The statement was not provided and the requirement remains outstanding and is now urgent. 14(2)(a)(b)16(2)(m) The Registered Manager 31/05/06 DS0000027492.V295603.R01.S.doc Version 5.2 Page 26 The Oaks / Woodcroft 4. YA33 18(1)(a) 5. YA35 18(1)(c)(i) 6. YA36 18(2) must set up suitable day care provision for all service users that meets their needs. Following receipt of the draft report mentioned above, Ms Preston said that the manager and senior staff were addressing this issue and were working hard to secure a placement for one particular service user to attend day care services by 28th February 2006. This requirement remains outstanding and is now urgent. The Registered Persons 31/07/06 must examine evening staffing arrangements to ensure that sufficient staff are on duty for long enough not only to provide personal care to those people who need it, but also to enable other residents to have a stimulating and appropriately wide range of activities. The Registered Persons 31/08/06 must ensure that, when applicable, all care staff complete foundation training within six months of taking up their posts. The use of Common Induction Standards (available free from the Skills for Care website) would perhaps provide a suitable alternative. The Registered Manager 31/05/06 must ensure that all staff have individual supervision sessions at DS0000027492.V295603.R01.S.doc Version 5.2 Page 27 The Oaks / Woodcroft the intervals laid down. 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. Refer to Standard YA3 YA8 YA14 YA20 YA23 Good Practice Recommendations The Registered Manager should encourage care staff to have a coordinated and consistent approach to innovative work with residents The Registered Manager should take up with Regulation 26 visitors misunderstandings relating to Residents’ meetings. The Registered Manager should consider ways of introducing more evening activities for residents. The Registered Manager should remind care staff of the importance of giving medication on time. The Registered Persons should consider ways of training staff, who might be lacking in confidence, in the Protection of Vulnerable Adults. If they wish, this could be quite informal and on an individual basis. The Registered Persons should consider providing reportwriting training for staff to increase their confidence and job satisfaction and add to the professionalism of the work force. 6. YA35 The Oaks / Woodcroft DS0000027492.V295603.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispin’s 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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