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Inspection on 10/09/09 for Oakhurst Court Nursing Home

Also see our care home review for Oakhurst Court Nursing Home for more information

This is the latest available inspection report for this service, carried out on 10th September 2009.

CQC 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 CQC judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

It is evident talking to members of staff that the emotional health of the service users at the home is of a high priority and that staff are pro-active in maintaining and supporting service users with their emotional needs in order to maintain their quality of life. The home and its staff are committed to supporting the service users in accordance with their needs and wishes. This was evidenced through feedback received from surveys and comments made on the day by service users and their families. The manager and staff are very committed to providing the best end of life care they can and care staff continue to receive training in this field and the nurses are trained to provide palliative care. The home offers plenty of space for those people with dementia who like to walk about during the day and very pleasant well maintained grounds which can be enjoyed by all. The service users are also able to help in the growing and picking of fruit and vegetables, which they have enjoyed. The home locally sources ingredients for the meals provided, using a local farm for meat and a local market for fruit and vegetables. Checks have been made to ensure they meet required safety and hygiene standards.

What has improved since the last inspection?

The systems for ordering, recording and administering medication now meet the required standard. The bedrooms identified as needing attention during the previous inspection have been refurbished and in some cases new flooring has been purchased. This has also had the effect of eliminating the odours in some service users’ rooms. Risk assessment have improved however they do need to be dated and review dates need to be documented. The activity programme has been improved along with the way activities undertaken by individual service users are recorded.Oakhurst Court Nursing HomeDS0000013343.V377390.R01.S.docVersion 5.2

What the care home could do better:

The home has now met the requirements of the last inspection. However the good practice recommendations at the last inspection about menus, this still do not offer a real choice with snacks available if the main meal is not liked for example. Meal times are the highlight of the day for many people and it is also another way of ensuring people get choice. The daily record of the care, service users receive through the day should be developed to ensure they provide enough detail regarding the support given. Most entries just give the heading from the care plan such as personal care and the number. It does explain what the service users were able to manage for themselves about their personal care for example whether they had a bath or a shower.

Key inspection report CARE HOMES FOR OLDER PEOPLE Oakhurst Court Nursing Home Tilburstow Hill Road South Godstone Surrey RH9 8JY Lead Inspector Sally Hall Key Unannounced Inspection 10th September 2009 08:45 DS0000013343.V377390.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oakhurst Court Nursing Home Address Tilburstow Hill Road South Godstone Surrey RH9 8JY 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) 01342 893043 01342 892690 pamela.milne@oakhurstcourt.co.uk Oakhurst Court Limited Mrs Pamela Elizabeth Milne Care Home 57 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Old age not falling within any other category (OP) The maximum number of service users to be accommodated is 57. 2. Date of last inspection 20th August 2008 Brief Description of the Service: Oakhurst Court Nursing Home provides nursing and personal care for older people with dementia who may have physical and sensory disabilities and various health conditions. The home is for people of mixed gender from 60 years of age. This large detached property is set in beautiful landscaped grounds in a semirural location and has good car parking facilities. It has been extended and refurbished over recent years, and care taken to tastefully combine the modern and period features of the building. Godstone village is a short drive by car where there a small range of shops, a church, public houses and restaurants and access to public transport. Bedroom accommodation is mostly single occupancy with en-suite facilities, arranged on the ground and first floor and served by two passenger lifts. Communal areas are on the ground floor. These comprise of a choice of three lounges and large dining area, which is multi-functional and also used for social and recreational activities. The building is wheelchair accessible throughout and WC’s and assisted bathrooms are on both floors. The home has a fire alarm and nurse call system and is equipped with hoists, grab rails and other suitable aids. Fees are available on request and depend on the type of room choosen. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 5 Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means the people who use this service experience good, quality outcomes. We agreed and explained the inspection process with the Registered Manager at the start of the inspection. The focus of the inspection was to assess Oakhurst Court in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Older People. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. We used a varied method of gathering evidence to complete this inspection, pre-inspection information such as the previous report and discussion and correspondence with the registered provider was used in the planning process to support the inspector to explore any issues of concern and verify practice and service provision. The home had completed an Annual Quality Assurance Assessment questionnaire (AQAA), which was received prior the site visit to the home. This provided us with information relating to what the home considers it does well, what has improved within the last 12 months and what they could do better. Survey questionnaires were also sent to the home prior to the inspection for distribution to service users, staff and other health professionals, their responses have been included in the report. Documentation and records were read. Time was spent reading written policies and procedures, reviewing care plans and records kept within the home. Other documents viewed included risk assessments, pre-admission assessments, staff rota, training records and recruitment records. We identified five people who use the service for case tracking, speaking with one of them whilst assessing the available information held in the home pertaining to the care provision for them. In addition we met with the other people who use the service and their family, which gave us a good opportunity to find out about the quality of care being provided by the home and understand the impact the care provision has on their quality of life. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 7 What the service does well: It is evident talking to members of staff that the emotional health of the service users at the home is of a high priority and that staff are pro-active in maintaining and supporting service users with their emotional needs in order to maintain their quality of life. The home and its staff are committed to supporting the service users in accordance with their needs and wishes. This was evidenced through feedback received from surveys and comments made on the day by service users and their families. The manager and staff are very committed to providing the best end of life care they can and care staff continue to receive training in this field and the nurses are trained to provide palliative care. The home offers plenty of space for those people with dementia who like to walk about during the day and very pleasant well maintained grounds which can be enjoyed by all. The service users are also able to help in the growing and picking of fruit and vegetables, which they have enjoyed. The home locally sources ingredients for the meals provided, using a local farm for meat and a local market for fruit and vegetables. Checks have been made to ensure they meet required safety and hygiene standards. What has improved since the last inspection? The systems for ordering, recording and administering medication now meet the required standard. The bedrooms identified as needing attention during the previous inspection have been refurbished and in some cases new flooring has been purchased. This has also had the effect of eliminating the odours in some service users’ rooms. Risk assessment have improved however they do need to be dated and review dates need to be documented. The activity programme has been improved along with the way activities undertaken by individual service users are recorded. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 8 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users can be confident their needs are assessed prior to admission. Intermediate care is not provided. EVIDENCE: Five pre admission assessments were viewed. Evidence from these demonstrated that a pre admission assessment is carried out to enable the manager to make a judgement as to whether the home will be suitable for and can meet the needs of the individual. These assessments include information gathered from care managers and health professionals. Upon admission, assessment is ongoing with the information from all the assessments informing the care planning and risk assessments. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 11 The home does not provide intermediate care. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from being competently assessed and supported with regard to their health and personal care needs, but more detailed care plans about all service users individual needs, wishes and preferences would ensure staff are better informed. EVIDENCE: Five care plans were selected at random, all contained evidence of individual needs, with further evidence of regular reviews. However, the plans were not person centred and were repetitive from person to person in many cases, i.e. personal care, continence, read the same for each service user. Reviews are taking place and detail the changes required to meet service users newly assessed needs, however these were not found to be recorded on the care Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 13 plan itself. Some plans seen had been in place since 2007. Care plans when reviewed and changes have been identified should be rewritten to reflect those changes so that staff are fully aware of the support individual service users need. These issues were discussed with the manager who plans to review all care plans to include the service users wishes and preferences to ensure the plans are person centred. The manager has been made aware that although staff are providing individualised care, accurate documentation within the care plan remains a requirement. It was also recommended that the home give consideration to language used on the care plan. Currently the assessed need is described as ‘problem’. This is a negative use of language and a more appropriate title would be ‘need’ or ‘agreed need’. The record written by staff daily about the care they provide for each individual was not detailed enough and in many cases listed the headings in the care plans and their numbers. However observation through the day, conversations with service users, their families and surveys received, it was evident that staff do provide a high level of individual care. The records do need to reflect this and record the time of events and outcomes. Risk assessments were seen in response to risks having been identified in the assessment process. However although this has improved since the last inspection a shortfall in the risk assessment process was noted. Currently risk assessments were not all dated and none contained review dates. The manager has been made aware of this. All the service users and their relatives spoken to confirm that their privacy is respected and staff were seen to knock on doors before entering. Observation of interaction between staff and residents throughout the visit confirmed that privacy and dignity is respected in the home. Several service users during the day said how happy they are in the home. All families spoken to said they were more than satisfied with the care their relative receives and praised staff for the way in which they carry out their duties. When asked or surveyed about how people felt about the care in the home phrases were used such as: ‘Nothing is too much trouble.’ Everyone is treated as an individual.’ ‘You couldn’t ask for better care.’ ‘The staff are so kind and helpful.’ ‘I can’t fault it’ and ‘the staff are always on hand when needed, treating everyone individually’. The home follows the Liverpool Care Pathway ensuring that peoples end of life care needs and desires are discussed and recorded. The home has also worked closely with the palliative care team and staff training is high priority. Evidence was seen on individual files that the home makes arrangements for service users to see the chiropodist, doctors and other health care professionals when they need to. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 14 The arrangements for medication have changed since the last inspection and the medication is now dispensed by the pharmacy into a, Monitored dosage system (MDS), where medication is dispensed in separate, monthly blister packs for each service user. We viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, however the protocols for the administration of PRN/s Required Medication were not available. The manager was made aware and stated she would supply these The home has a clinical / medication room. Medication cabinets and trolleys were evident in a dedicated room. The medication record sheets observed were completed correctly. A small audit of medication was undertaken and again this was correct, showing nursing staff are administering and recording the medication correctly. The controlled drug arrangements were also viewed and found to meet the current requirements of the NMC guidelines regarding medication which nurses have to adhere to. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from being supported to make choices and a wide range of activities that are tailored to meet their needs are provided. Service users can feel confident that they are offered a well balanced diet and supported to eat their food where they choose, however this would be further improved if a real choice was available at meal times. EVIDENCE: Service users are supported to live their lives as they choose. Routines are flexible and restrictions are kept to a minimum. There is a variety of activities on offer such as art and craft, hand massage, playing cards, knitting, reminiscence, gardening and exercise, which service users may choose to take part in, if they wish. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 16 The Activity Organiser appeared highly motivated and has a good and pleasant manner with service users. Understanding dementia, she also organised a number of activities on a one to one basis. The records kept regarding individual service users and the activities they have taken part in or refused have really improved since the last inspection. A varied activity programme is display around the home however it could be improved by adding pictures of the activities for example so people with dementia can understand them more easily. The programme included some work in the gardens and staff were pleased to say that service users had been able to pick some fruit and vegetables from the garden that they had been able to help grow. The hairdresser was in the home and this was part of the activity for that day, it was clear from talking to service users that they really enjoyed having their hair done. In the afternoon as it was a warm and sunny day reminiscence took place in the garden and many stayed there for afternoon tea. The dining room is in the centre of the home and lunch time was observed with a good ratio of staff to assist service users. We observed staff encouraging service users to finish their meals and others who needed more support were helped to eat their meal. The weekly menu appeared nutritious and the manager explained that the chef had worked with service users to decide the menu. However there was no real choice offered on the menu, with just meat pie or vegetable pie for lunch. The alternative is always vegetarian although they only have one person who is vegetarian and they are not offered an alternative either. The manager explained if they do not like what is on the menu they can have omelettes or salad. The home offers special diets taking particular care to ensure that food is nutritious and takes account of specialist dietary needs. The manager said the home prides it self on purchasing the meat and fruit for the home from local providers and stated all the food is freshly cooked. Service users spoken to after the meal said that they liked it, one said the food is always very nice, another said it’s Ok, if you like what you are given. The dining rooms were well laid out with tables attractively set, although a number of service users eat in the lounges. Currently the home is not recording all the meals taken by service users as is necessary. Service users have the opportunity to attend church services held in the home. All service users have their spiritual needs recorded on their care plans. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an effective complaints system in place which service users are aware of where capacity allows. Families are also aware of its contents. Service users are fully protected by adult protection policies and procedure EVIDENCE: The home had a written complaints procedure, which was seen. Feedback received and comments made within service users surveys confirmed they were aware of the contents and felt free to voice their concerns where capacity allows. The home has received one complaint since the last inspection. On information received from the manager complaints received have been dealt with in a positive way to achieve the best outcomes for the complainant. However a record of conversations and action taken is necessary providing evidence that complaints have been dealt with satisfactorily with in the time scales. Any safeguarding referrals made have also been seen to be managed appropriately. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 18 Homes Policy for protecting people, the whistle blowing procedures for staff and safeguarding adult policy were viewed. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training has been provided in dealing with abuse for all staff. Criminal Record Bureau Checks (CRB) has been obtained for all staff. The Manager is aware of her obligations with regard to ensuring the safety of service users and protecting them from abuse. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from living in a home that provides safe access to comfortable indoor and outdoor communal areas. However the odour detected in two lounges did detracted form the homely feel. The standards of internal, external decoration and facilities were found to be good. EVIDENCE: Since the last inspection when shortfalls in the cleanness of some bedrooms were noted, the home has replaced flooring, decorated and replaced a large amount of bed linen. The bedrooms seen were clean and odour free. The new Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 20 flooring used to replace some carpeted rooms and is slip resistant. The manager has been made aware that it would not be appropriate to replace all carpet in service user’s bedrooms and should only be changed where it is appropriate for the service users and in consultation. When new service users come into a room without carpet a carpet must be offered. An unpleasant odour was noticeable in two of the service users lounge areas the manager stated that one of these had been cleaned the previous day; however it detracted form the homely feel. Families spoken to had also noticed the odour. The homes grounds were well tended and gave pleasant views, and appear well used by service users and families. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users can feel confident that their care, social and emotional needs are supported by care staff in sufficient numbers to meet their needs who are trained to the required standards. Residents are fully protected by the recruitment procedures within the home. EVIDENCE: The ratios of care staff to service users are determined according to the assessed needs of service users. Observations made during the inspection of the number of staff available in the home gave us the opinion that sufficient care staff were on duty to support service users to meet their personal needs and take all reasonable steps to ensure their health and safety. Staff spoken to confirmed that rotas are covered when staff are absent. Service users families talked with also confirmed that there seemed to be sufficient staff on duty when they visit. Feedback from surveys confirmed that service users are Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 22 generally well supported with their needs. The manager stated that staffing is constantly kept under review. The home employs ancillary staff such as cleaners, laundry and cooks, thus allowing care staff the time to meet the needs of service users. The staff training records indicated the training that had been undertaken. Individual and group staff training needs had been identified. From documentary evidence seen the standard of staff training was good overall with the large majority of staff completing basic courses and the home has achieved an NVQ (National Vocational Qualification) Level 2 or above care qualification for more than 50 of care staff. Staff training is ongoing and further training is booked. The manager confirmed that the home has a development programme for all new staff, which meets Sector Skills Council’s workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. The staff files sampled showed the recruitment procedure the home undertakes, which includes the submission of an application form detailing all previous work history, requests of proof of identity and copies of qualification certificates, seeks two written references, and confirms work status. The home’s recruitment files evidenced all qualified Nurses working within the home are currently registered with the Nursing and Midwifery Council. It was evidenced that all staff have a current Criminal Records Bureau check (CRB) and Protection of Vulnerable Adults (POVA) check. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users on the benefit from living in a well run and managed home. Service users and or their relatives can be confident that their views and opinions effect how the home is run and be assured that service users best interest are wholly safeguarded by appropriate policies and procedures. EVIDENCE: Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 24 The manager is a registered General Nurse and has eight years management experience in care home settings. The manager has obtained the Registered Managers Award, a National Vocational Qualification (Level4) in Health and Social care management and has gained a diploma in dementia care. The management of the home has made a number of improvements since the previous inspection. Most of the shortfalls identified at the previous inspection have been completed; however the care planning systems still needs improvement. The manager has voiced her commitment to making sure care plans become person centred and that documentation in the service users files is improved to reflect the standard of care being provided. Quality assurance was discussed and the views and opinions of many of the service users are sought where capacity allows. They or their family confirmed a great deal of satisfaction in living within the home and felt confident that the staff and management valued their views and opinions. The manager confirmed that the home does undertake quality assurance by means of asking service users/families to complete questionnaires. Statutory visits by the provider to monitor standards within the home are taking place monthly, and reports completed at each visit were seen. The visits assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. Policies and procedures required in the home are in place and have been reviewed in a timely way. Oakhurst Court Nursing Home DS0000013343.V377390.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 Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X 2 3 Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 15 Requirement A service user plan of care which is person centred and shows the service users wishes and preferences must be to be formulated individually with service users and/or their family as their capacity allows Timescale for action 15/11/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP15 Good Practice Recommendations It is recommended that more detail about the care provided is detailed in the daily records. For the menu to include a choice of cooked meal served at lunchtime. Oakhurst Court Nursing Home DS0000013343.V377390.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission South East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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