Inspection on 30/05/06 for Three Oaks Care Home

This inspection was carried out on 30th May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Three Oaks Care Home 01/05/07

Three Oaks Care Home 06/12/05

Three Oaks Care Home 25/04/05

Three Oaks Care Home 08/02/05

Three Oaks Care Home 27/09/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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 Hertfordshire AL6 0PR Lead Inspector Angela Dalton Unannounced Inspection 30th May 2006 15:30p Gwynfa Close (14) DS0000054490.V296836.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 Gwynfa Close (14) DS0000054490.V296836.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. Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gwynfa Close (14) Address 14 Gwynfa Close Welwyn Hertfordshire AL6 0PR 01438 712939 01438 712939 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) Three Oaks Care Home Limited Mrs Tracy O`Dwyer Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8), Physical disability (8), of places Physical disability over 65 years of age (8) Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home may accommodate people with a physical disability (when associated with a learning disability) 6th December 2005 Date of last inspection Brief Description of the Service: The home was first registered with the Hertfordshire County Council Inspection Unit 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 disabilities. The home provides support to individuals in developing and maintaining links with the local community. The aim is to allow individuals to have a say in how the home is run regardless of their disability. Fees range from £1259.86 to £1770.27 per week Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection consisted of a site visit on 30th May 2006 between 3.30pm and 9pm. The inspector spent time with service users and staff to gain an insight into the home. Two service users were on holiday and another is currently receiving care elsewhere. Staff evidently know the service users well and are aware of their needs through experience. Some development is needed regarding documentation to reflect the high standard of care given, as it is not reflected in care plans. The proprietor was present for the majority of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Risk assessments have been devised but do not fully explain the action needed should the risk occur. One service user has a stark bedroom because of their complex behaviour. Alternatives have not been fully explored and expert advice has not been sought. Staff do not have any training in Makaton (a form of sign language) which would benefit service users and facilitate better communication. One member of staff whom the Inspector met during the inspection spoke limited English. Another member of staff is able to translate but both staff do not always work the same shift. The manager and proprietor must ensure that additional support is available to support both service users and staff as this may leave both service users and staff at risk. Training has been provided but it is difficult to assess the level of comprehension. Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 6 Medication amounts did not tally with the amounts given and this must be addressed. 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) DS0000054490.V296836.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Documentation requires review and presenting in a service user friendly format. Quality in this outcome is adequate; this judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was made at the previous inspection to update the statement of purpose and service user guide. The copy of the statement of purpose that the Inspector was shown was dated November 2004 and staff did not initially know where to find it but were directed after a telephone call to the manager. The requirement has again been made and must be met. It is important that prospective commissioners of the services, service users and their relatives are provided with up to date information that reflects the current practices of the home. Documentation is not in a form easily understood by service users and some consideration should be given to this. A basic assessment is in place and forms the basis for the care plan. Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Care plans and risk assessments are in place but need expansion to reflect the good standard of care delivery. Quality in this outcome is adequate; this judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are being reviewed and an additional life plan is being introduced to introduce a person centred element to documentation. Some expansion is needed to reflect the good care that is provided. The same is true of risk assessments. One example is a service user who has sleep apnoea but there is no explanation of what the condition is and its effects. The risk assessment does not expand on what to do if the service user becomes unwell. Weight records are kept but there was no accompanying plan or guidance when a loss was identified. A keyworker system has been implemented to ensure that service user views and choices are sought on a one to one basis. Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Service users’ choice regarding activities, meals and social contacts is observed. Quality in this outcome is adequate; this judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users have a varied routine. The Inspector was present for dinner and choices are available if the main option is declined. Staff said they usually ate with service users but miscalculated the amount of food required with some away on holiday so this did not happen during this. The proprietor agreed to research a more age appropriate alternative to the ‘bibs’ used by some service users. Staff work closely with families and decisions are often made in partnership. Staff should be mindful to ensure that the decisions are made in the interests of the service user and may benefit from support from advocacy services. The home has its own transport but its use is dependant upon a driver being on duty (the proprietor will often fulfil this role). Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 11 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 & 20 The dignity of service users could be better observed. A safe medication system is not in place. Quality in this outcome is adequate; this judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are well cared for by a staff team who know them well. One service user’s bedroom is spartan and staff explained that this was to manage their complex needs. If this has been agreed as a multidisciplinary decision the care plan should reflect this (as it does not currently). Specialist advice regarding the environment has not been sought. Staff have not received any Makaton training and there is the assumption that the team have this knowledge from members of the multidisciplinary team who support the service. This form of sign language would assist service users to communicate with staff as some service users currently use Makaton. One service user has a hearing impairment and would be better able to make their needs known. Staff interact well with service users but should be aware that they were observed to interact with the calmer service users when they became active and their quiet behaviour was not rewarded. Signs were displayed on bathroom doors but depicted which were residents’ bathrooms and which were for staff. It is suggested that generic signs are displayed to depict bathrooms. Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 12 Medication was checked and the amount of tablets did not match the amount recorded. Medication must reconcile as this could mean service users may have missed medication. Dual records are kept and although they reflected the numbers in the packet they were inaccurate when the amount administered was checked. Temperature records must be kept to ensure medication is stored correctly. Medication that is not stored according to the manufacturers instructions may no longer be effective. Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Polices and procedures are in place to protect residents from abuse. Quality in this outcome is good; this judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has the Hertfordshire County Council Adults at Risk procedure on display, of which most staff are aware. They also had an understanding of the whistle blowing procedure. Revision of the policy may be useful, as some staff needed prompting with regard to the content. A strategy meeting was recently called under the local Adult Protection procedure and issues raised by family members were resolved in this forum. The complaints procedure is on display in the entrance hall where visitors to the home can refer on it if they were unhappy with any aspect of the service provided. Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 14 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): 24,29 & 30 Some maintenance work is required. Good infection control is not assured. Quality in this outcome is adequate; this judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean and odour free. Some areas of the home are being used for storage (Christmas lights were being kept in a bathroom) and the proprietor agreed to address this. Some maintenance issues were evident but there is a plan to address them in the near future. A toilet seat was broken; cracks were seen in some of the new rooms; a freezer handle was broken; plugs were missing; a bedroom door was difficult to open as a new carpet had been fitted. A copy of the maintenance plan has been requested. As some service users have sensory needs a computer may be an additional way for staff to engage with them and consideration should be given to this. The laundry room has no separate hand basin and a requirement has been made to provide paper hand towels and pump action soap to ensure effective infection control as bar soap is currently being used. Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 15 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): 32,34 & 35 Staff are competent and receive ongoing training. Staffing records have been requested by the Commission. Good infection control is not assured. Quality in this outcome is adequate; this judgement has been made using available evidence including a visit to this service. EVIDENCE: Adequate staffing levels are in place and staff receive regular mandatory training. As the manager was unavailable on the day of inspection a requirement has been made to send details of new employees’ recruitment records to the Commission which a senior member of staff agreed to do. As discussed earlier the manager must ensure that oversees staff have a good understanding of the needs of the service users and the home. Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 16 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): 37,39 & 42 Better observation of health and safety is needed. Financial records are inconsistent. Quality in this outcome is adequate; this judgement has been made using available evidence including a visit to this service. EVIDENCE: The focus of the home is the service users and their personalities are evident. One bedroom door was held open with a tray and the office door has a wedge in place. A safe alternative must be employed that meets the requirements of the fire safety officer. Finances were checked and a small discrepancy was evident in one service user’s cash tin. Some service users have two signatures when transactions are carried out whereas others only have one. The good practice of two signatories should be used consecutively. No emergency lighting checks have been conducted and these must occur monthly. Night staff have not attended a fire drill and this is also required to ensure both their safety and that of residents. Staff and service user names should be recorded when they have participated in a fire drill. Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 3 X 2 2 2 Version 5.2 Page 18 Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4&5 Sch 1 Requirement The statement of purpose and service user guide must be reviewed, updated and sent to the Commission for Social Care Inspection. THIS REQUIREMENT WAS MADE AT THE PREVIOUS INSPECTION. Care plans must fully identify how service users’ needs are monitored managed and met. Risk assessments must fully identify how service users’ needs are monitored managed and met. The dignity of service users must be observed. The medication records must appropriately be maintained at all times. THIS REQUIREMENT WAS MADE AT THE PREVIOUS INSPECTION. Medication storage temperature records must be kept. Medication amounts must reconcile. A copy of the maintenance plan must be submitted to the Commission to identify the DS0000054490.V296836.R01.S.doc Timescale for action 31/07/06 2. 3. YA6 YA9 15 12 31/08/06 31/08/06 4. 5. YA18 YA20 12 13(2) 31/07/06 07/06/06 6. YA24 13 31/07/06 Gwynfa Close (14) Version 5.2 Page 19 timescale of work. 7. 8. YA30 YA34 13 Schedule 2 Pump action soap and paper 30/06/06 hand towels must be available in the laundry. Copies of recent employees’ 30/06/06 recruitment records are to be submitted to the Commission. Evidence must also be sent to prove that visiting professionals who have unsupervised access to service users (e.g. Reflexologist) have had a CRB check. The Health and Safety of Service 31/07/06 Users and Staff must be assured. 9. YA42 13 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 YA1 Good Practice Recommendations Information about the home (Statement of Purpose) and Service Users’ guide should be in a user friendly format for service users. A computer should be available for service users. Two signatures should be in place for financial record transactions. 2. 3. YA29 YA41 Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire 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. Extracts may not be used or reproduced without the express permission of CSCI Gwynfa Close (14) DS0000054490.V296836.R01.S.doc Version 5.2 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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