Inspection on 25/04/05 for Three Oaks Care Home

This inspection was carried out on 25th April 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Three Oaks Care Home 01/05/07

Three Oaks Care Home 30/05/06

Three Oaks Care Home 06/12/05

Three Oaks Care Home 08/02/05

Three Oaks Care Home 27/09/04

Similar services:

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Coopers Mill Ltd

Sun Court Nursing Home

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Paradise Lodge

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Upaya Ananda

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

CARE HOME ADULTS 18-65 Gwynfa Close (14) 14 Gwynfa Close Welwyn Herts AL6 0PR Lead Inspector Alison Butler Unannounced 25 April 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. Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Gwynfa Close Address 14 Gwynfa Close, Welwyn, Herts, AL6 0PR 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) 01438 712939 01438 712939 Three Oaks Care Home Ltd Mrs Tracey ODwyer CRH Care Home 7 Category(ies) of Learning Disability (7)LD, Learning disability registration, with number over 65 years (7) LD/E, Physical Disability (7) of places PD Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 08 February 2005 Brief Description of the Service: The home was first registered with Hertfordshire County Council on 28th October 1997. Gwynfa Close is a large detached bungalow set at the end of a cul-de-sac in the village of Welwyn. the building has been extended and converted for use as a residential care home for people with learning and physical disabiltiies. the home provides support to indivdiuals in developing and maintaining links with the local community. The aim is to allow inidividuals to have a say in how the home is run regardless of their disability. Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out during the afternoon it was also used as a site visit as the proprietor had applied for a variation on the home for an extra place to be registered. The work had recently been completed. The inspector was in the home for approximately 3 hours. Before the visit the records of CSCI contact with Gwynfa Close since the last inspection were checked. The inspector spent some time talking to residents and observing the interaction between residents and staff. Discussions and contact was made with 4 residents, 2 staff as well as the proprietor. Care and administrative records were checked. What the service does well: What has improved since the last inspection? What they could do better: The home must implement a quality assurance monitoring system to ensure the views of the residents; families and visiting professionals are reviewed, recorded and acted upon, with a report being made available to interested parties and a copy forwarded to the Commission For Social Care Inspection. The Statement of Purpose and Service User Guide need to be updated to include the additional room and staffing to allow the variation to be completed. Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 6 Medication records should be maintained appropriately and a bring forward system should be put in place to allow for ease of reconciliation at any point in time to be carried out. A review of residents care plans should be carried to minimise the amount of repetition and to make them a user-friendly document with old information archived. The manager should consider a review of the keyworker system and the deputy being responsible for overseeing keyworkers and ensuring reviews are carried out as appropriate. All information should be signed and dated by the person responsible for writing it this would ensure that it is shown to be in date and a review has been carried out as appropriate. 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. Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 2 Residents and/or their families receive information about the service, which enables them to make a choice about whether or not, they might wish to live in the home. The residents’ needs are assessed prior to admission to ensure the home are able to meet their needs. EVIDENCE: Although a Statement Of Purpose and Service Users guide is available these documents must be reviewed and amended to reflect the proposed increase in accommodation and staffing. Service users records showed that assessments had been carried out to ensure the needs of the residents could be met by the home. Information regarding families’ views is recorded on the residents care plan in agreement with them. Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 & 10. Resident’s needs are assessed and any goals are reflected within their care plans. Support and advice is given to the residents to help them make decisions about all aspects of their lives. All information is handled appropriately and confidentially. EVIDENCE: Care plans showed that the action required by staff is written appropriately and in detail. Each resident is allocated a member of staff (keyworker) who is responsible for the recording of the information and discussing it with families, other professionals and the staff team as appropriate to ensure the needs of the individuals are met. One care plan had not been updated as a new bed had been purchased to and therefore this need has now been met. A discussion took place with the deputy and the proprietor to try and reduce the repetition of information within the care plans and to archive old information to ensure only current information is contained within the file and these are user friendly documents. It is recommended that both the residents and the staff would benefit from a review being carried out on the keyworker system and looking at who is responsible for which resident, as the deputy is responsible for three residents at the time of this inspection making it difficult in ensuring the information is kept up to date. The deputy role could instead oversee the staff Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 10 that become keyworkers in their completing of information, (as monthly reviews had not been carried out on the files examined). The confidentiality policy still remains missing from the policy file and the recommendation made at the previous inspection remains in place. Risk assessments are in place although some of these had not been signed and dated and therefore unable to verify if they are in date or have been reviewed. Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 & 14 Residents are able to choose which activities to take part in the local community. They are able to engage in appropriate leisure activities of their choosing. EVIDENCE: Due to the complex needs of the residents finding out their views is difficult, some of the residents are able to show by facial expression when asked about their lives and they appear to be happy. One resident was listening and singing along to music to which they appeared to be enjoying. A resident spoke about his holiday that had been arranged and was able to talk about where they were going and what they are expecting to see in Blackpool. Each resident has a daily programme in place detailing what they are to be doing and when. Holidays have been booked in which the residents have helped choose where they would like to go with the use of brochures or previous visits they have experienced. Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 12 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) 18, 19 & 20. Residents are able to receive personal support in the way they prefer, with the constraints of health & safety of themselves and staff. Health needs are taken care of and recorded within their plans of care. Polices and procedures are in place to ensure they have their medication administered appropriately. EVIDENCE: Each resident has a plan in place and where possible a female carer deals with female residents personal care. Support required by individual residents is written in the care plans giving detailed action of how their needs are to be met. The staff are knowledgeable about what each resident requires and how their needs are to be met. Whenever a resident visits the GP, dentist chiropody or other health professionals these visits are recorded on their files with details of any further treatments or visits required. Medication records showed that where additional prescription medicines are added to the Medication Administration Record (MAR) sheet they must be placed in a new section and not written over an already prescribed medication which is still prescribed although not being administered at the time. Staff must ensure that when hand writing the information it is copied exactly as written on the dispensing label. None of the residents are able to administer their own medication. A system should be put in place where medication that has not be used up the previous month should be carried forward onto the new MAR sheet to ensure that reconciliation can take place at any time during the month and all Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 13 medication can be accounted for. The epilepsy protocol requires a review with staff and the community nurse, as the information recorded following a recent seizure was not the same as the protocol, although staff had taken other factors into account and it would be seen as good practice to include these into the protocol. Comprehensive policies and procedures are in place covering medication administration, storage and disposal. Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 14 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 & 23 Views of residents are listened to and acted on. Policies and procedures are in place to protect residents from abuse, neglect and self-harm. EVIDENCE: The home has on display in the office the Hertfordshire County Council Adults at Risk procedure which staff are all aware of the process and of the whistleblowing procedure, this is covered as part of the induction process. The complaints procedure is on display in the entrance hall where visitors to the home could refer to if they were unhappy with the service provided at Gwynfa Close. The deputy stated that no complaints had been received since the last inspection. Due to the complex needs of the residents their views are discussed and listened to during 1 to 1 sessions with their keyworkers and/or through their families and friends who visit them. Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 15 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, 27 & 30 The home is well kept, homely and safe. All areas visited were found to be clean and fresh. EVIDENCE: A check on the additional new room that has been built was carried out; it was in excess of 12 square metres with a wash hand basin and built in wardrobe. During the building work a resident’s room had been affected and this is also in excess of 12 square metres with a wash hand basin and built in wardrobe. The building of the extra room has created a storage cupboard, which is waiting shelving to be added. A walk in shower room has been built which will provide the residents with extra choice. The original shower room has been refitted and decorated to provide staff with shower facilities. The staff sleep in room and the laundry room have been swapped. This provides staff a quieter room but where they can still be woken during the night if their services are required. The flooring in the corridor has been replaced with flotex as this provides a more appropriate surface for the residents who use wheelchairs it also provides a more hygienic and easily cleanable surface. The proprietor had arranged for a plumber to visit the scheme as there was a problem with the water pressure and some test were being carried out to see if the problem could be rectified Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 16 more cost effectively as the alternative is to have the mains re-laid outside of the home. The home was cleaned to a high standard. Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 17 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) 33 &35 Residents are supported by consistent and experienced staff. EVIDENCE: The rotas showed that 3 staff cover the morning to assist the residents with getting up and going off to their various day time activities. A minimum of 2 staff cover the afternoon and evening. If activities have been arranged then extra staff are brought in to ensure residents are supported as appropriate. 1 member of staff cover the waking night supported by a sleep in person who can be woken if necessary. There has been a consistent staff team who have worked for a number of years and are knowledgeable about the needs of the residents. Additional staff will be needed as soon as the variation has been agreed to increase the numbers of residents and this should be included in the Statement of Purpose and Service User Guide. Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 18 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) 39 & 42 Gwynfa Close is well managed. The health, safety and welfare of residents, visitors and staff are promoted through a series of checks and risk assessments. A quality assurance system is still to be implemented to ensure a self-monitoring review is in place. EVIDENCE: The proprietor is a regular worker and usually covers the morning shift supporting residents in attending their day activities. Examination of the fire records showed they had recently introduced a new recording system and all other records had been archived. These records will be re-examined at the next inspection to verify checks are carried out regularly. There had been a full service carried out in January 05 by T & J Fire. A quality assurance audit and report remains outstanding from the last inspection although the timescale has not yet expired. Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 19 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 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x x Standard No 31 32 33 34 35 36 Score x x 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gwynfa Close (14) Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4&5 Requirement The statement of purpose and service user guide must be reviewed, updated and sent to the Commission for Social Care Inspection. The medication records must appropriately be maintained at all times. A review must be carried out to establish the quality of care provided by Three Oaks Care, a report made available to all interested parties and a copy forwarded to the Commission For Social Care Inspection. This has been brought forward as the timescale has yet to expire. Timescale for action by 31st May 2005 2. 20 13(2) 3. 39 24 Immediate as of 25th April 2005 and henceforth by 30th June 2005 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 6 Good Practice Recommendations A review of the keyworker system should take place to I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 21 Gwynfa Close (14) 2. 6 3. 4. 5. 6. 7. 9 10 20 20 37 ensure the completing of reviews and updating of information is carried out as appropriate. The care plan format should be reviewed to eliminate the amount of repition within the care plans. Information no longer required should be archived and ensure the care plan files are a user friendly document. Risk assessments should be signed and dated to ensure they are in date and are reviewed as appropriate. A confidentiality policy should be made available and a copy forwarded to the Commision For Social Care Inspection. A bring forward system should be in place to allow for reconcilliation of medication at anytime. The epilepsy protocol should be reviewed with both staff and the community nurse to ensure a consistent approach is used at the time of a seizure happening. The manager should continue to work towards her Registered Managers Award. This has been brought forward from the previous inspection. Gwynfa Close (14) I52 s54490 Gwynfa Close v223109 250405 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City, Herts AL7 3BQ 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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