Care Home: The Oaks

Similar services:

• Thorndene
• Insight - Eastchurch
• Southfields
• Magenta
• Seabourne House
• 33 St John`s Church Road
• Dovedale Court
• Lyncol House

What the care home does well The staff team are committed to providing a safe and homely environment. The house is kept very clean and pleasant and was seen to be comfortable for the people that live there. Each person has their own room, which is their own private space. The service has person centred plans and health action plans to record the needs, goals and aspirations of service users. The staff wereobserved to follow the care plans in place closely to support people with their everyday skills and to ensure they meet all their other needs. All policies and documents used at the home are in a format which is accessible and understandable to service users, this ensures people are kept up to date and well informed. Activities and personal support is well organised. Service users access local amenities and are engaged in meaningful activities such as going to local colleges. Meals at the home offer both variety and choice. Individuals are included in the planning of menus by the use of pictures and equally involved in food shopping and food preparation. The provider and manager check the quality of the service regularly and ask people who live in the home what they think. Relatives are encouraged to visit the home when they wish and to give their views. All comments, concerns and suggestions are taken seriously and given proper consideration to the benefit of service users. What has improved since the last inspection? The appointment of the house manager has provided much needed management stability, leadership and direction to the staff team. A deputy manager has now also been appointed to support the manager`s role. The home`s statement of purpose and service user guide has been updated to reflect the manager`s details as recommended in the last inspection report. The majority of the staff team have received Person Centred Active Support (PCAS) training which they could clearly evidence had changed the way they now support individuals living at the Oaks. It was further explained that a PCAS approach to supporting people enables individuals to voice choice, become more independent and be included in every aspect of their life. It focuses on the individual`s abilities, rather than any disability they have. This approach is clearly to the benefit of service users. Throughout the service, there was clear evidence of a good awareness and understanding of equality and diversity issues, which translated into positive outcomes for people living there. There has been some redecoration and refurbishment of areas within the home, which has greatly improved the general environment. The manager has a rolling programme of further improvements. A new modern kitchen has been installed. A hand washbasin in one of the communal bathrooms, previously found to be too small, has been replaced with one of a much more useful size. The relaxation room at the rear of the home was assessed for its fitness of purpose and overall safety following a requirement issued at the last inspection. Since that time the room has been the subject of much attention regarding the improvements required to make it safe for use. Numerous meetings have taken place between Avenues Trust and the Housing Association that owns the property to agree a way forward. In the interim period the room has been kept locked with access denied to service users to ensure their safety and protection. The home has plans to reopen this facility as soon as new windows are installed and the room is fully refurbished and commissioned as safe for people living and working in the home to use. What the care home could do better: The new house manager must submit an application for registration to the CSCI (Commission for Social Care Inspection) to ensure service users benefit from a well run home and we are satisfied that she can clearly evidence her fitness to run the service. CARE HOME ADULTS 18-65 Oaks (The) The Oaks 1a Spencer Way Redhill Surrey RH1 5LF Lead Inspector Marion Weller Key Unannounced Inspection 11th March 09:35 Oaks (The) DS0000013736.V359389.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 Oaks (The) DS0000013736.V359389.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. Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oaks (The) Address The Oaks 1a Spencer Way Redhill Surrey RH1 5LF 01737 789404 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) www.theavenuestrust.co.uk The Avenues Trust Ltd Post Vacant Care Home only - PC 6 Category(ies) of Learning disability (6) registration, with number of places Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users who can be accommodated is: 6 26.10.2006 Date of last inspection Brief Description of the Service: The Oaks is a small residential care home providing accommodation, personal care and support to adults with a learning disability. The home is run by The Avenues Trust Ltd, who manages a number of similar homes in the area. The Oaks is situated between Salfords and Redhill. The home occupies a modern detached building with service users bedroom accommodation arranged across the first floor of the premises. All bedrooms are for single occupancy. There are staff on duty 24 hours a day to meet individuals needs. The home benefits from a good-sized secure garden to the rear with patio seating and a barbecue area. There is a small amount of off road parking at the front of the premises and opportunities to park in local roads nearby. The current fees charged for this service range from £460 to £1060 per week depending on people’s individual needs. Please contact the manager for further details. Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was a key inspection of The Oaks. The Manager did not know we (the Commission) were coming to inspect the home. As part of the inspection, surveys were sent out before the visit to some people involved with the home that were asked to give their views about the service. Surveys were also sent to some relatives of people living at the home. The inspector was in the home from 9:35am to 2.00 pm and spent some time looking at records and documents, observed how the home was being run and how staff were supporting people. A complete tour of the premises was also undertaken. Some people living at the home have communication difficulties and judgements were made about them based on their mood, behaviour and information given by staff. Survey responses included: ‘‘They always have plenty of activities for the clients to attend” “House is calm and well organised” “The organisation in general appears to be very well run” And “Manager is willing to try new things” “Problems are dealt with without fuss” Two respondents had some concerns about recent staffing levels and the home’s reliance on bank staff to cover vacant hours on rosters. The manager and the staff gave their full cooperation throughout the inspection. What the service does well: The staff team are committed to providing a safe and homely environment. The house is kept very clean and pleasant and was seen to be comfortable for the people that live there. Each person has their own room, which is their own private space. The service has person centred plans and health action plans to record the needs, goals and aspirations of service users. The staff were Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 6 observed to follow the care plans in place closely to support people with their everyday skills and to ensure they meet all their other needs. All policies and documents used at the home are in a format which is accessible and understandable to service users, this ensures people are kept up to date and well informed. Activities and personal support is well organised. Service users access local amenities and are engaged in meaningful activities such as going to local colleges. Meals at the home offer both variety and choice. Individuals are included in the planning of menus by the use of pictures and equally involved in food shopping and food preparation. The provider and manager check the quality of the service regularly and ask people who live in the home what they think. Relatives are encouraged to visit the home when they wish and to give their views. All comments, concerns and suggestions are taken seriously and given proper consideration to the benefit of service users. What has improved since the last inspection? The appointment of the house manager has provided much needed management stability, leadership and direction to the staff team. A deputy manager has now also been appointed to support the manager’s role. The home’s statement of purpose and service user guide has been updated to reflect the manager’s details as recommended in the last inspection report. The majority of the staff team have received Person Centred Active Support (PCAS) training which they could clearly evidence had changed the way they now support individuals living at the Oaks. It was further explained that a PCAS approach to supporting people enables individuals to voice choice, become more independent and be included in every aspect of their life. It focuses on the individual’s abilities, rather than any disability they have. This approach is clearly to the benefit of service users. Throughout the service, there was clear evidence of a good awareness and understanding of equality and diversity issues, which translated into positive outcomes for people living there. There has been some redecoration and refurbishment of areas within the home, which has greatly improved the general environment. The manager has a rolling programme of further improvements. A new modern kitchen has been installed. A hand washbasin in one of the communal bathrooms, previously found to be too small, has been replaced with one of a much more useful size. The relaxation room at the rear of the home was assessed for its fitness of purpose and overall safety following a requirement issued at the last inspection. Since that time the room has been the subject of much attention regarding the improvements required to make it safe for use. Numerous meetings have taken place between Avenues Trust and the Housing Association that owns the property to agree a way forward. In the interim Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 7 period the room has been kept locked with access denied to service users to ensure their safety and protection. The home has plans to reopen this facility as soon as new windows are installed and the room is fully refurbished and commissioned as safe for people living and working in the home to use. What they could do better: 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 summary of this inspection report can be made available in other formats on request. Oaks (The) DS0000013736.V359389.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 Oaks (The) DS0000013736.V359389.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 The people who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home’s information documents would provide prospective service users or their representatives with sufficient information for them to make an informed decision about moving to the home. Individuals can be confident the home can meet their needs. EVIDENCE: The home has developed a statement of purpose and service users guide that is made available in formats appropriate for each persons needs in the home. Information documents also ensure that any prospective service users, their families or their representatives would have enough information to make an informed choice about moving in. Both information documents are regularly reviewed and updated. The home has not had any new admissions since it opened. Avenues does however have a development manager who would work and liases with the service to further support individuals who might want to move into and on from the service. Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 10 The manager explained that any prospective service user would have a full assessment of their needs in which they would be fully involved before they were offered a place at the home. There is an organisational policy on admission and discharge. The format for pre admission assessments covers people’s emotional, physical, social and psychological needs. It also addresses any cultural or specific needs they may have. If the assessment shows that the home would be able to meet the person’s needs, they would be offered a place at the home. The assessment will then be used to develop a care plan for how needs would be met. Oaks (The) DS0000013736.V359389.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. JUDGEMENT – we looked at outcomes for the following standard(s): 679 The people who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users individual plans of care are in a suitable format to fully support their involvement in planning the care and support they receive. They contain comprehensive information, including details of individual’s needs and goals. They also incorporate known preferences and choices, and include in depth risk assessments. EVIDENCE: Most of the staff team have received Person Centred Active Support (PCAS) training which they could clearly evidence had changed the way they now support individuals living at the Oaks. It was further explained that a PCAS approach to supporting people enables individuals to voice their choices, become more independent and be included in the planning for every aspect of their life. Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 12 Staff provide just enough support and help to allow people to experience success and to enable them to participate successfully in meaningful activities and realtionships. The staff reported that PCAS promotes independence, social inclusion and gives people control over their lives. The manager said that there has been noted improvements to some individuals communication skills and confidence since they adopted this approach. Some residents display challenging behaviour. The manager explained that Avenues has a behavoiur support manager and health and safety advisor available to work with staff teams who need help and guidance to ensure the welfare of everyone involved in an individuals care. Any restrictions to service users choices are managed through their personal support plans and risk assesments which are reviewed every six months and up dated regularly. They are made available in a pictorial format to service users so they are fully involved and kept informed of their plan of care. Risk assessments were observed to be detailed and comprehensive and to adequatly secure the individuals welfare and safety. The staff spoken with said they encourage realtives and other people who matter to the resident to be involved in care planning meetings. Staff spoken with were knowledgable about residents choices, needs and views and skilled in ensuring they were being met. Each service user have a named keyworker who works closely wih them. Oaks (The) DS0000013736.V359389.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 The people who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in the activities they enjoy and which meet their needs. There are opportunities for their personal development and they are supported to maintain contact with their family and friends. Service users are offered a healthy nutritious diet and enjoy their meals. EVIDENCE: Service users have numerous opportunities for fulfilling activities and education and some are able to attend East Surrey College which offers supported learning courses. The home also has its own transport to enable service users to access community based facilities. The provider organisation has a sports and active lifestyle group which looks at how their homes can encourage service users to take part in more sport. There is also an Avenues ‘Zoom’ magazine available which aims to share information, Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 14 good ideas and create opportunities for people to think about planning their own events and activities. For instance, last summer the home took part in a community project which they called ‘opening up’. Service users were supported to invite in neighbours and some of the local church members to a get togeather. With support service users planned a BBQ, did the shopping and helped with the cooking. The manager stated that as a result the event significantly improved the relationship with their close neighbours and they were also invited to take part at the local church during harvest festival. The home supports service users to maintain family links and friendships. Family and advocates play a big part in the life of the home with some service users making regular visits to stay with relatives for periods of each week or over the weekend. Others go out with their relatives for special events. Relatives are encouraged to visit as often as they wish. Observations confirmed service users had unrestricted access in the home and staff supported service users in maintaining their independence. Routines of daily living are flexible. The home has a weekly menu plan and a record of meals eaten by service users to monitor the provision of healthy diets. Service users are involved in planning the menu by the introduction of a pictorial meal planner and in the preparation of meals. The menus seen was nutritious and offered variety and choice. Oaks (The) DS0000013736.V359389.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 21 The people who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users receive personal care support in the way they prefer and they can be confident that their health care needs will be met in full. EVIDENCE: People who live in their home are cared for and supported in a way, which promotes their privacy and dignity. For instance, staff was seen to knock on doors before entering service users bedrooms and people were spoken to respectfully. A survey respondent had a concern that on occasions some staff can display old-fashioned attitudes in their approach to service users needs and this can be perceived as somewhat institutionalised. Details of preferences in respect of personal care support needs are clearly recorded on individual care plans. The home also has comprehensive health action plans for each service user and all individuals have access to a GP, dentist, dietician, optician and chiropodist to maintain good health. End of life and serious illness plans are in place for each individual and are regularly Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 16 reviewed. Staff receive care of the dying training, which includes offering support to the bereaved. The home has a robust policy for the safe storage and administration of medication. Staff receive comprehensive training and until they have satisfactorily completed the course they are not permitted to handle medication to fully protect service users from harm. Regular competency testing of staff in relation to medication administration is undertaken and exercises are recorded. Medication administration recording sheets were sampled they were all dated and signed by staff, there were no errors or unexplained gaps found. The home keeps a record of medications returned to the pharmacy, which was signed and dated by care staff and the pharmacist. There is a list of homely remedies approved by service users GP’s. Annual pharmacy audits are carried out. Risk assessments around refusal of treatment are in place and known to staff. During monthly quality assurance visits, the provider organisation includes a check on one service users medication to regularly monitor service users welfare and safety The rota planning provides for mixed genders and skills on shifts, there is a shift leader on each shift who knows the service users preferences and allocates the work accordingly. All service users moving and handling risk assessments are comprehensive and reviewed regularly. Oaks (The) DS0000013736.V359389.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 The people who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The required policies, procedures and practices are in place in the home to ensure that service users are safeguarded from the potential for harm or abuse. EVIDENCE: There were no records of any complaints having been received since the previous inspection and we, the Commission are not aware of any complaints regarding the service. Records indicated that complaints would be responded to within the provider’s guidelines and the manager evidenced a clear awareness of procedure. The manager and deputy explained that they have a close relationship with resident’s families and advocates and are always keen to resolve any issues of discontent at an early stage. All the required policies, procedures and practices are in place in the home to ensure that service users are safeguarded from the potential for harm or abuse The homes complaints procedure is available to service users in both a pictorial and audio format to ensure they now how and who to complain to. Recruitment procedures for new staff are robust. Prior to employment all staff receive Pova and enhanced CRB checks to fully protect service suers from any potential for harm. Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 18 Staff spoken to, stated that they had undertaken training in Safeguarding Adults, they were able to explain the concept of whistle blowing and understood their role in the event of having to instigate such an action. All staff members, inclusive of bank and agency staff are made aware of procedures during their induction. For permanent staff, safeguarding is discussed and revisited regularly on supervision. The home is arranging Mental Capacity Act training this year. The manager said she had already attended. Notifications of restraint are in place in addition to risk assessments which are reviewed regulary in service users personal care plans. Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 28 30 The people who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a safe, clean and comfortable environment. There are good standards of furnishings and fittings that meet the needs and tastes of the people who live there and which encourage independence. EVIDENCE: There has been some redecoration and refurbishment of certain areas within the home since the last inspection, which has greatly improved the general environment. The manager has a rolling programme of further improvements planned such as redecoration of some the service users bedrooms. A new modern kitchen has been installed. A hand washbasin in one of the communal bathrooms, previously found to be too small, has been replaced with one of a much more useful size. Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 20 The relaxation room at the rear of the home was assessed for its fitness of purpose and overall safety following a requirement issued at the last inspection. Since that time the room has been the subject of much attention regarding the improvements required to make it safe for use. Numerous meetings have taken place between Avenues Trust and the Housing Association that owns the property to agree a way forward. In the interim period the room has been kept locked with access denied to service users to ensure their safety and protection. The home has plans to reopen this facility as soon as new windows are installed and the room is fully refurbished and commissioned as safe for individuals living and working in the home to use. The home is kept very clean and hygienic. Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 34 35 The people who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Interactions observed between staff and service users evidenced a high degree of respect and skill in working both with specific individuals who can be challenging and service users as a group. Staffing is kept under review to ensure the needs of people living there are met at all times. Service users further benefit from the home’s robust recruitment practices. EVIDENCE: Staff evidenced a comprehensive understanding of service users needs. They were observed to be skilled in practice, consistently respectful and caring even under pressure and demonstrated a good rapport with some individuals whose behaviour could at times be challenging. There was sufficient staff on duty to meet the needs of the service users on the day of the visit. Day rosters are based around service users activities and individual needs and are kept under review. There is one waking night staff and one sleep in night staff. There are clear lines of accountability and staff are aware of the demands of their role and the home’s expectations of them. Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 22 New staff are subject to a 6 monthly probation periood. During this time they receive structured induction and fundation training. This is supervised by the house manager. The induction checklist reflects Skills for Care competency elements. Within the service budget 5 paid training days are allocated per individual. The manager stated however that staff receive at least 13 training days within their first 6 months. Service specific training is identified during regular supervision sessions and performance related reviews of staff members take place. Mandatory training is planned and undertaken by all staff. The manager confirmed that the home exceeds the 50 standard for NVQ qualified staff. The manager confirmed her intention to ensure all staff are either qualified or working towards an NVQ qualification over the next year to further benefit service users. The home has robust recrutiment procedures for the protection of service users. All staff found to be appointable are required to have at least two satisfactory references and all gaps in employment are explored. They must be POVA checked prior to employment and also have a satisfactory enhanced CRB check. All staff have a copy of the code of conduct.and the practises set by the GSCC available to them. A survey respondent said, “‘‘All new staff are very good, so excellent recruiting” Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 The people who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, it has effective quality assurance systems in place to further develop the service to residents benefit. The manager must submit an application for registration to the CSCI to evidence her fitness to run the service. EVIDENCE: The house manager was found to be suitably qualified and competent to undertake her role in the home. She was previously registered by the CSCI for another home provided by the Avenues Trust nearby, She is therefore known to the regulator. She has however not yet gone through the fit person process Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 24 with the Commission for the service provided at the Oaks. The manager stated that since the last inspection she had completed the ‘fit person’ application forms to become the registered manager for the Oaks on two separate occasions. On the first occasion they were sent to CSCI, but despite investigations there were no records of them having been received. On the second occasion she spoke of them being lost at the Avenues HQ, who checks all applications before sending them to the CSCI. She stated her firm intention to register and provide evidence of her fitness to run the service. The inspector is confident of her intent to do so. A strong recommendation will be made in this respect within the report and compliance will be monitored. Quality assuring the service takes a high priority. The results of numerous quality assurance exercises and other monitoring tools were seen. Some required to be undertaken by the demands of regulation, but the majority were provider led quality monitoring tools. For example, an exercise undertaken in January 2008 looked specifically at how well the home did in offering service users a ‘healthy lifestyle’. The completed results were good with the home achieving a score of 92 . The home has a local policy on health and safety and staff receive training. Records indicated that staff also receive mandatory training in fire prevention and emergency evacuation procedures, food hygiene, moving and handling, and first aid. Environmental risk assessment are in place in place in addition to those that seek to secure individual residents safety. All accidents and incidents are recorded and reported including those the home is required to tell the Commission about. Certificates for regular equipment servicing, portable appliance testing, fire equipment, and gas boiler are also up to date and in place. A survey respondent stated, “There is a safe atmosphere in the home’” Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 25 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 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 3 25 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 3 3 3 2 X 3 X X 3 X Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 YA28 Good Practice Recommendations It is recommended that the lean too structure at the rear of the home, designated as the relaxation room, continues to remain locked and out of use to service users until all remedial work is fully completed and the room is refurbished and commissioned as safe for use. It is very strongly recommended that the house manager fulfils her stated intention to make application to the CSCI (Commission for Social Care Inspection) for registration to ensure that she can evidence her ‘fitness’ to run the service at the Oaks. Delay or Failure to do so may lead to enforcement action being taken. 2. YA37 Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Oaks (The) DS0000013736.V359389.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!